Essential Skills for Mental Health Care
By Dr Jim Crabb and Emma Razi
Illustrations by Molly Cooke Front cover by Mr Abdallah JoJo Peter
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Essential Skills
For Mental Health Care
By Dr Jim Crabb and Emma Razi
With special thanks to:
Dr Akwasi Osei Acting Chief Psychiatrist and Medical Director of Accra Psychiatric Hospital Dr Anna Dzadey Medical Director of Pantang Hospital Mabel Eshun Regional Coordinator of community psychiatric nurses, Greater Accra Rosemary Mutako Deputy Regional Coordinator of community psychiatric nurses, Greater Accra Rev. Joseph Abotsi Community Psychiatric Nurse in charge of Ablekuma Sub-metro Agnes Sam Community Psychiatric Nurse in charge of Okaikoi Sub-metro Philomena Nkansah Community Psychiatric Nurse in charge of Ashiedu Sub-metro Winfred Darko Community Psychiatric Nurse Mary Anago Community Psychiatric Nurse Agnes Akpey Community Psychiatric Nurse
The authors would like to thank the Founding Director of BasicNeeds; Mr Chris Underhill, MBE and the West Africa Representative; Mr Lance Montia for their valuable assistance which made the production of this manual possible.
Mr Abdallah JoJo Peter is a talented artist currently working in Accra, Ghana. He kindly provided the artwork for the front cover of this manual. Mr Abdallah JoJo Peter has schizophrenia. However, with the right treatment and care, he is stabilised and is able to lead a fulfilling and happy life.
1st Edition, September 2007 Copyright © 2007 Dr Jim Crabb Permission granted to reproduce for personal and educational use only. Commercial copying, hiring, lending is prohibited. 3
Preface
This manual will prove to be a very good companion to the student of mental health including medical students, nursing students and clinical psychology students. It will also benefit the professional mental health practitioner including doctors of psychiatry, psychiatric nurses and clinical psychologists. As the title indicates, the manual contains the ‘essential skills’ necessary for mental healthcare. It is not a textbook and is not intended to replace textbooks in psychiatry. Instead it focuses on the day to day skills one would need in the field, at the clinic or on the ward.
Dr Jim Crabb, the principal author, has practiced psychiatry in Ghana for three months during 2007. He worked at Pantang Hospital, at a number of polyclinics in Accra as well as in a number of remote districts in the Upper East Region. His acute observation in this short period and his rapid assessment of our needs and situation on the ground have prompted and informed the writing of this manual. The recommendations he has provided are relevant and noteworthy. Dr Crabb's stint in Ghana has been part of a BasicNeeds programme to find short-term expatriate mental health workers to alleviate a limited human resource in Ghana. This manual is a welcome collaboration between BasicNeeds and the Ghana Health Service.
The manual has also been enriched by the editorial work of Ms Emma Razi, a healthcare communication specialist and the wife of Dr Crabb. The reader of this manual will surely enrich his or her skills in mental healthcare.
Dr Akwasi O. Osei Acting Chief Psychiatrist Ghana Health Service
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For Mr O. Lamptey 5
Contents Page Number Foreword 8 a) How to use this manual 8 b) DON’T PANIC! Having a crisis plan 9 Chapter 1: An introduction to mental illness 1.1 What is mental health and mental illness? 11 1.2 Why should we be interested in mental illness? 11 1.3 What causes mental illness? 12 Chapter 2: Assessing someone with mental illness 2.1 Before the assessment 14 2.2 During the assessment 15 2.3 Important questions to ask 16 2.4 Important things to observe and record (the mental state examination) 19 2.5 The physical health check 20 2.6 Getting the whole story 22 Chapter 3: Treatments for mental illness 3.1 Medicines (biological treatment) 23 3.1.1 The golden rules of mental illness and medicine 24 3.2 Talking cures (psychological treatment) 27 3.2.1 Counselling 28 3.2.2 Problem solving work 28 3.2.3 Relaxation and breathing work 30 3.2.4 Crisis planning 31 3.2.5 Coping strategies 31 3.2.6 Different ways of looking at a situation 33 3.3 Building the best life possible (social treatment) 34 3.3.1 How to rebuild a person’s life 34 3.3.2 Working with a person’s family 35 3.3.3 Relapse prevention 37 Chapter 4: The different types of mental illness 39
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Chapter 5: Organic mental illness
5.1 Delirium 42
5.2 Epilepsy 45
5.3 Dementia 51
Chapter 6: Substance misuse 55
Chapter 7: Psychosis 65
Chapter 8: Mood disorders
8.1 Depression 70
8.2 Mania and manic depression (bipolar mood disorder) 75
Chapter 9: Anxiety disorders
9.1 Panic attacks, phobias and generalised anxiety disorders 80
9.2 Obsessive compulsi ve disorder (OCD) 84
9.3 Acute stress reactions 88
9.4 Post traumatic stress disorder (PTSD) 89
9.5 Medically unexplained symptoms (somatisation) 92
Chapter 10: Mothers and babies 97
Chapter 11: Mental retardation 102
Chapter 12: Mental illness and young people 107
12.1 Enuresis and encopresis 108
12.2 Attention deficit hyperactivity disorder (ADHD) 111
12.3 Conduct disorder 115
12.4 Depression in young people 117
12.5 Child abuse 118
12.6 Specific learning difficulties (SLD) 121
Chapter 13: Mental illness and old age 123
Chapter 14: Headaches 124
Chapter 15: Emergencies due to medicines 7
15.1 Acute dystonic reactions 129
15.2 Anti-psychotic induced Parkinsonism (AIP) 129
15.3 Akathisia 130
15.4 Tardive dyskinesia (TD) 130
15.5 Neuroleptic malignant syndrome (NMS) and serotonoergic syndrome (SS) 131
15.6 Discontinuation syndrome 131
15.7 Lithium toxicity 132
Chapter 16: Managing violence and aggression 133
Chapter 17: Managing your own mental health 136
Fact sheets for you to photocopy
1. My crisis plan 137
2. Sleep hygiene 138
3. Relaxation techniques 139
4. Epilepsy 140
5. Dementia 141
6. Psychosis 142
7. Depression 143
8. Mania 144
9. Mental retardation 145
10. Delirium 146
Appendices
1. The safe administration of medicines for mental illness 147
2. Emergency treatment of physical illness 164
Bibliography 169
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Foreword
How to use this manual
This manual has been designed to provide you with the essential information you need to help people with mental illness. It does not tell you the solution to every problem you may face, but it will hopefully show you how to deal with most situations. It will also let you know when you need to get extra help. This will mean that you can provide good, safe care to all the people you work with. We also hope it will prevent any worries you may have and will help you to enjoy your work! This manual is aimed to help the work of all mental health professionals . The initial chapters provide an introduction to mental health (experienced professionals may wish to use these chapters to teach others). The later chapters and the appendices will be of more use to experienced health professionals who prescribe medicine.
Some information in this manual may be new to even experienced health professionals, particularly regarding the use of medicines. When writing this book we collected the most up-to-date research and guidelines on what treatments work for mental illness. We have then compared this information with the treatments that are available in Ghana today to make our recommendations. The main aim of this manual is to help you in your work. If you provide effective treatments that are proven to work, the people you help will get better more quickly and everybody’s life will be easier!
At the end of the manual there are some fact sheets about some of the mental illnesses, and other ways you can help people. Please feel free to photocopy these fact sheets and give them to the people you help and to their families. If a person is not able to read you can tell the person what the fact sheet says and ask them to memorise it. The fact sheets can also be downloaded and printed out from the following website: www.basicneeds.org
We would be very grateful for any comments about this manual. It is always nice to know when people have enjoyed reading it, but also please do not be afraid to let us know of ways we can improve the manual. Please send any comments to:
Every day around the world people are being Basic Needs Ghana helped free from the chains of mental illness. We 108/20 Osabu Street would like to thank you for your part in this work Abelenkpe and wish you all the very best! PO Box AT1603
Achimota-Accra The Basic Needs Team Ghana Email: [email protected]
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DON’T PANIC! Having a crisis plan
Often when people start a new job they worry about facing problems they do not know how to deal with. This is called a crisis. At some stage when you are helping people with mental illness you will have a crisis. However don’t panic! You can very easily come up with your own plan to deal with any crisis.
The first thing to do is to sit down when things are calm and work out who you are going to speak to when there is a crisis. Next, think about what you would do if that person is not around. This is called imagining the ‘worst case scenario’. Once again however we do not panic. We calmly think again of another person we can go to for help or we think of something else we can do. It is helpful to keep repeating this process until we are happy we have solutions for all of the ‘worst case scenarios’ we can think of.
For example: A Volunteer does not know what to do with someone who has had an epileptic seizure. First, the Volunteer:
Contacts their local polyclinic. However the ‘worst case scenario’ means that the phones at the clinic are not working! What is the next thing they can do?
They go to the clinic. However the ‘ worst case scenario’ means it is closed for a public holiday! What is the next thing they can do?
They phone the local hospital. However the ‘worst case scenario’ means that the phones at the hospital are also not working! What is the next thing they can do?
They can go with the person to the hospital. Big hospitals never close and there is always someone there to help. This should cover every ‘worst case scenario’. What a relief!
This technique is called Crisis Planning. We will show how you can use it to help people with mental illness in chapter 3.
Complete the diagram on the next page as your own Crisis Plan. Fill in the names and contact details of all the people on the diagram who you will contact in the event of a crisis. It is best to do this now when things are nice and calm. This will mean you can act quickly and safely when there is a crisis, instead of searching in a panic for telephone numbers. 10
A person with a mental illness has a crisis: Contact a local volunteer Name:………………………………………… Telephone Numbers:………………………...
If they do not know what to do: Speak to the contact person at local polyclinic or health clinic. Name:…………………………………………. Address:………………………………………. Telephone Numbers:…………………………
If you cannot speak to the contact person on the telephone then go to the local polyclinic or health centre. But if you still don’t have any luck:
Decide if the problem is due to a mental or physical health problem?
If it’s a mental health problem If it’s a physical health problem (e.g. malaria, gastroenteritis, chest infections)
Contact the local psychiatric hospital Contact the local hospital Name of hospital:……………… Name of hospital:…………………… Address:…………………………… Address:……………………………… Telephone numbers:……………. Telephone numbers:………………..
If you cannot speak to someone at the local hospital for advice on the telephone, then go there with the person you are trying to help.
Now you know what to do if you are ever faced with a crisis or need to contact someone else for help! Keep a copy of this crisis plan with you when you are doing your work in case you need it.
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CHAPTER 1
An introduction to mental illness
1.1 What is mental health and mental illness?
Good mental health is when an individual can think clearly, solve problems they face in life, enjoy happy relationships and feel spiritually at ease. Mental illness is anything that affects a person’s thoughts, emotions or behaviour that results in: 1. A negative effect on the person or those around them. 2. An obvious change in their personality. 3. Friends or relatives feel that what is happening to the person is strange and hard to understand.
However, everybody can experience unusual thoughts, emotions or behaviour especially when sleeping, praying or when alone in the dark. For example, dreams can sometimes be more vivid and realistic than usual. Sometimes people experience strong spiritual feelings when praying or meditating. And occasionally people feel frightened when alone in the dark. It is important to remember that these experiences are not a sign of mental illness and are completely normal and are nothing to worry about. However, if these experiences had a negative effect on the person, resulted in a change in their personality and confused others, then this may be a sign of mental illness.
1.2 Why should we be interested in mental illness? • Mental illness affects us all. One in every four of us will become mentally ill at some point in our lives. • Mental illness is a great burden on every country. Research from around the world shows that around 40% of all people attending health clinics have some kind of mental illness. • Four of the top 10 most disabling conditions in the world are mental illnesses. Depression has been shown to cause the most disability of all illnesses. It even causes more disability than malaria! • Most mental illnesses can be treated in simple, cheap ways and most people with mental illnesses can be stabilised. Some severe mental illnesses cannot be fully cured. But like diabetes, the right medicine can keep the symptoms away. • People who know someone with mental illness are often frightened or ashamed of them. This means the person with mental illness can also feel frightened and ashamed. This fear and shame about mental illness is called stigma. Stigma can stop people with mental illness from getting better, finding a job or having good relationships. Everyone with mental illness can have good relationships and nearly everyone with mental illness will be able to do some kind of job. 12
So let’s summarise. Mental illness:
• is very common • places a great burden on every country • causes great suffering and disability • can be treated cheaply and easily • does not stop a person from having a good life or supporting their family.
As you can see, by trying to help people with mental illness you are playing an important role in overcoming one of the biggest problems facing humanity. Good for you! Give yourself a round of applause!
1.3 What causes mental illness?
This is a very good question! We know that most mental illnesses are caused by a chemical imbalance in the brain, but we don’t always know what causes the chemical imbalance. However we do know of lots of things that make mental illness more likely to happen, including: • Being related to someone who has had a mental illness. • Having problems early on in life; a mother being very ill during her pregnancy, problems during the birth of a baby and a child being seriously ill when they are growing up. • Having had a serious head injury. • The use of illicit drugs. • The use of too much alcohol. • Any kind of big stress. For example unemployment, homelessness, divorce, childlessness or death of a loved one. • Any kind of serious physical illness.
We think that these things combine to create a chemical imbalance in the brain. It is this chemical imbalance that leads to mental illness.
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When thinking about what may have led to mental illness, it can be helpful to think of the person’s life like a story. For example, think of a 27 year old man called Mensah Boateng from Accra:
This example shows that a number of events can lead to mental illness. In Mensah’s case he was doing badly at work. Once Mensah became mentally ill, further events kept Mensah unwell; he began to drink more alcohol and smoke more cannabis.
When people ask you to explain the cause of mental illness, try to be honest. You can never know what the exact cause is but you may have some ideas based on their life story: • What was their early life like before the mental illness started? • What happened at the time the mental illness started? • What happened after the mental illness began?
Of course we can not change the past. Often family members will feel guilty about things that may have happened in the past. It is very important to address this ( see section 3.3.2 ). Things that happened at the time a mental illness started and after a mental illness began can often be changed. These changes can be used to stop mental illness from returning. In this example Mensah needs to learn how to cope with stress, stop drinking alcohol and smoking cannabis. Stopping a mental illness from happening again is called relapse prevention, we will return to this topic in chapter 3. 14
CHAPTER 2
Assessing someone with mental illness
2.1 Before the assessment People with mental illness are often thought to be more dangerous than the general public. Studies have shown that this is not true. However, it is important to remember your own safety comes first. Take exactly the same safety measures when meeting someone who you think might be mentally ill as you would when meeting any stranger.
Safety tips for mental health workers • Let people know where you are going, and what time you are coming back, even if it is in the same building. Mention which room you will be in and how long you plan to be there. • Always leave a contact telephone number. Ideally, carry a mobile phone (don’t forget to have the battery charged and have enough credits to make an emergency call). • Find out if the person you are seeing has been violent to themselves or anyone else. If the person has been aggressive or violent in the past, do not see them alone. If you feel afraid about seeing someone, always speak to a senior colleague beforehand, and get advice about the best thing to do (see your crisis plan). • Sit in the seat nearest to the door so you can easily leave the room if something bad happens. If you want you can move your seat closer to the door to make leaving the room easier. • Do not have objects between you and the door that may trip you up. • Be alert for signs that someone is becoming aggressive (see Chapter 16 for more information).
Always trust your instincts, if you feel that a situation is dangerous, politely make an excuse to leave the room. You could suggest a ten minute break for some fresh air. Once you are in a safe place, call a senior colleague for assistance. Never become over confident or think that by being in a dangerous situation you are being brave or dedicated. This is simply not true! You will not be able to help people with mental illness if you have been hurt. You need to look after your own health in order to help others.
This advice may seem very worrying but don’t panic ! Most people will never encounter a dangerous situation whilst helping people with mental illness. The above guidance is standard advice for anyone working with the public. When it comes to your personal safety prevention is better than cure. 15
2.2 During the assessment Assessing someone with a mental illness is not always easy. Here is a guide to help you to think about how to approach the initial assessment.
Introduce yourself Always introduce yourself to the person and explain what your role is.
Be calm , polite and respectful Always conduct yourself in a calm, polite and respectful manner. This does not mean you have to allow people to be rude to you (see chapter 16 on managing aggression and violence). However by being polite and respectful you show that you are in control. This can be very comforting to someone who is afraid. You are also showing others that people with mental illness deserve to be treated with dignity and respect like all other human beings. This will help to stop the stigma people with mental illness face. Finally, if you are polite and respectful then others are more likely to behave in the same way towards you.
Be gentle Approach the person in a gentle manner. Due to their illness, and the related stigma, they may be suspicious. It is best to win their trust by asking general questions first or by starting with a pleasant topic of conversation before enquiring about their health.
Do not laugh Never mock or laugh at anything strange a person says. This will stop them from trusting you and make them feel stigmatised. If a person with mental illness is laughed at, it will also make them upset or stressed. This will make mental illness worse.
Do not correct If the person says things that are strange or unbelievable do not try and correct them. Do not agree with them either. If you do correct someone when they give strange answers to questions, you may cover up the symptoms of the mental illnesses! Instead make sure they have understood the question you have asked and let them know that you have listened to their response. An example would be to say:
“Thank you for telling me that. I am grateful you could be so honest. I guess there are a lot of different ways of looking at the world”.
Get the whole story Always try and speak to the family or someone who knows what has been going on. Ask the person’s permission before you do this. It will show you respect them and it will help them to trust you more. Whilst it is very important to hear what is going on from others, it is also important that the person who is thought to be unwell has the chance to speak. Remember it is up to you as a trained health worker to decide if a person has a mental illness, not the person’s family. If the person is not allowed to speak or given enough time to answer questions by their family, you may miss important symptoms. You 16
may also wrongly diagnose a mental illness when a person is in fact healthy! If you can, speak to the family first and then speak to the person with suspected mental illness – alone.
Ensure privacy Always try and speak to the person alone (provided there are no safety issues). A person may have things they wish to share with you that they wish to keep private, even from their own family. In busy clinics you can speak in a quiet whisper. If a person tells you something that they wish to remain private you should respect this. The only exception is if they tell you about a plan to hurt themselves or anyone else. If this happens, contact someone senior for advice (see your crisis plan ).
Make time This is very important. Do not keep looking at your watch no matter how busy you are. Finding time when you are busy can be hard, however, it does make it easier for patients and their families to trust you. Having enough time at the beginning can also make life easier for you. It will prevent you going back for information you missed the first time.
Keep a report Always write details of your assessment clearly and in black ink. This makes it easier to photocopy later and allows your colleagues to see the results of your assessment. Write the date and time you saw the person. Sign and write your name and job title clearly, at the end of each entry. Write all the contact details possible for the person and anyone else you spoke to such as family members.
2.3 Important questions to ask When conducting an assessment, it is vital you record the following information. This information will be used to identify the person next time you see them.
Personal details Record the persons: age, gender, marital status, occupation, ethnic background, religion, language, contact details and their carers contact details. It is very important to get both sets of contact details. Sadly people with mental illness often lose contact with their family once they are separated from them (for example if they are hospitalised). They will need to be able to find their family once they get better.
Presenting complaint (PC) Often people say they have lots and lots of complicated problems. It can be difficult to know where to begin helping them. It is helpful to work out what their main problem is at the start of the assessment. A good way to do this is to ask the person, ‘What is your number one problem?’
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History of the presenting complaint (HPC) Find out about the problem. Get as many details as you can. Here are some questions you could use: • When or how did it start? Has it been over hours, days, weeks or months? • Has the problem ever happened before? • What stresses or changes have there been in your life recently?
Sometimes it can be difficult to know if the person is mentally ill or not. The following questions are called Golden Questions and can be used to identify whether a mental illness is present. If the answer to any of these questions is yes then it is likely a mental illness is present: • Do you have any problems sleeping at night? • Have you lost interest in your daily activities? • Have you been seeing or hearing things that other people can not hear? • Have you been feeling sad or unhappy recently? • Have you been scared or frightened recently? • How much alcohol have you been drinking recently? • Have you used any illicit drugs?
Medical history During the assessment it is also useful to find out about their medical background or history: • Are you taking any herbal medicine or tablets? • Have you had any physical illnesses in the past? • Are there any illnesses that run in the family? • Has anyone else in your family had a similar problem to you? • Has any medicine made you sick in the past? This will tell you if a person is allergic to any kind of medicine. If a person is allergic to a medicine it will have caused a skin rash or breathing problems. • Most people will not remember the name of the medicine that caused this, so find out what it was used for and maybe you can then work out what the medicine was.
Recent physical illness All mental illnesses are made worse by physical illness (particularly epilepsy, see section 5.2 ). Delirium is the most serious mental illness, it can kill people – and it is caused by a physical illness (see section 5.1 ). Always ask about recent physical illnesses when a person is drowsy, confused or whose mental illness has suddenly got worse. The following quick questions test for the most common physical illnesses you will see.
Has the person experienced any of the following over the last two weeks? • Fever, chills or sweats (a sign of infection). 18
• Malaria symptoms (fever, chills, bitter taste in the mouth, headache, abdominal pain, diarrhoea). • Cough or yellow / green sputum (a sign of chest infections). • Abdominal pain, vomiting or diarrhoea (a sign of gastroenteritis or typhoid). • Neck pains, headaches, vomiting and difficulties looking at bright lights (a sign of meningitis). • Pain passing urine or dark and bad smelling urine (can indicate a urine infection). • Always remember that asking these questions can save lives!
Safety questions It is very important to find out if there is any immediate action you need to take to ensure a persons safety. Make sure you ask the following safety questions. These are some of the most important questions in your assessment. If you are worried about any of the answers a person gives to these questions, contact a senior colleague for advice (see your crisis plan).
• How much have you been eating and drinking over the last few days? People with a serious mental illness may not be eating or drinking enough, or their carers may not be giving them enough food or water.
• Is anyone hurting you? People with mental illness sometimes falsely believe they are being hurt by other people. However people with mental illness are also sometimes bullied by others. Ask if anyone is hurting them and look for signs that would mean this was true for example: cuts, bruises or a person looking starved.
• Have you ever thought about hurting yourself or anyone else? This is a difficult thing to ask but it always needs to be done as it can stop someone killing themselves or anyone else. Asking this question saves lives . One way of asking about whether a person has considered hurting themselves or other people is to say:
“I understand that this is a difficult thing to talk about, but sometimes when people have been under a lot of stress and life is difficult they feel like hurting themselves or other people in order to feel better. I was wondering if you have ever felt this way?”
In nearly all cases people do not mind being asked this question in a respectful way. You can also explain that you are doing your job and that means keeping the person safe. If a person ever talks about harming themselves or anyone else, get advice at once (see your crisis plan ).
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2.4 Important things to observe and record (the mental state examination)
You can tell a lot from someone’s appearance, what they say and how they behave. This is called the mental state examination.
Appearance • What is their appearance like? Note if the person is clean or dirty and smelly. • Does it look like they can care for themselves? • Notice any cuts, bruises or marks. • Notice if the person smells of alcohol. • What is the persons face like? Does it look happy, sad, angry, blank, frightened or suspicious?
Behaviour What is the person’s behaviour like? Are they friendly or are they quiet and withdrawn? Do they make any strange movements?
Speech What is the person’s speech like? Is it too fast or too slow? Do they make sense?
Mood Does the person feel they are happy or sad? How does their mood seem to you?
Thoughts What are they thinking about? Do they have any worries? Do any of these worries seem strange or confusing? Is anything strange happening to the person’s body or mind?
Perception Is the person experiencing any strange sensations? People with mental illness may see, hear or feel things that others do not. These experiences are called hallucinations.
Cognition Is the person confused? There are some simple tests that you can carry out to check for confusion. • Ask them to repeat three simple words and remember them. For example: car, man and ball. Explain that you will ask them to repeat the words in a few minutes. This tests a person’s short term memory. • Ask them to repeat the words five minutes later. • Ask them to tell you what time of day it is, the day of the week, the month, year and season. • Ask them to tell you the name of the local area you are in. • Ask them to tell you their name, the year they were born and how old they are (make sure the date of birth and their age match up). If a person does not know the year they were born or their age you can ask them to tell you where they live. Check their answers are correct by asking people who know them. If a person knows the time, where they are and who they are they are said to be fully orientated. 20
• Ask them to subtract 7 from 100, if they answer 93 correctly ask them to keep subtracting 7. The numbers they give you should be 93, 87, 81, 74, 67 then stop. This is actually hard to do! If the person cannot do this ask them to count from 1 to 20 (or from 1 to 3 depending on their educational ability), and then to count backwards from 20 down to 1. This tests a person’s attention.
If a person did not go to school, or has mental retardation (see chapter 11 ), they may not be able to do these tests. Find out if this is the case. If a person who would normally be able to do these tests fails to answer questions correctly, they are confused and may be suffering from delirium. Section 5.1 explains what to do if you suspect someone has delirium.
Insight Some people with severe types of mental illness do not recognise that they are unwell. These people are said to lack insight. In order to test if a person has insight ask: • What do they think the cause of the problem is? • Do they think they are unwell? • Would they be happy to take medicine or other treatments?
Different types of mental illness show different things in the mental state examination. These things will be covered in the relevant chapter for each illness.
2.5 The physical health check
Often a physical illness can make mental illness worse. You should perform and record a physical examination in as much detail as you can when you first see a person with mental illness. A physical check up should always include physical observations. These are: • Pulse. This should be 60–100 beats per minute (bpm). If the pulse is greater than 100 bpm the person may not have had enough water to drink or they may have an infection. • Temperature. This should be below 37.5 degrees Celsius. If it is above this the person may have an infection. Ask about fevers, sweats or episodes of shaking even if you do not have a thermometer. • Blood pressure. High blood pressure is above 160/100 mm Hg. Low blood pressure is a systolic (the top number) blood pressure of less than 90 mm Hg. A high blood pressure may be caused by pain, agitation or hypertension. A low blood pressure can be caused by a person being dehydrated. • Capillary refill test. Squeeze the end of the person’s finger gently for three seconds then let go. The end of their finger should have gone pale but it should quickly go back to the same colour as their other fingers. If it takes more than three seconds for the pale finger to go back to a normal colour, the person may be dehydrated. • Breathing rate. Count how many breaths a person takes in one minute (one breath is breathing in and then out). If they take less than 10 or more than 20 breaths in a minute, or it looks like they are struggling to breathe it may indicate a very serious physical illness. 21
Physical observations can be done by anyone and are an extremely useful way of telling if a person is physically sick. They are especially useful in the assessment of children who may not be able to tell you they are physically sick. Children normally have different physical observations to adults. See chapter 12 for normal physical observations in children.
If a person has evidence of a physical illness from the questions you have asked, or if you find anything wrong with the person’s physical check-up, they may be suffering from delirium or a physical illness. Ask a senior colleague about what to do next (see your crisis plan). People with delirium or a physical illness need immediate treatment. The physical illness needs to be treated before the mental illness. They need to be taken to a senior health worker who is qualified to deal with these problems. If a senior health worker is not available, appendix 2 gives details of emergency treatment for delirium and physical illnesses.
If you are a senior health worker, the following tests can also be used to detect most of the physical illnesses that affect mental illness.
Urine tests • Dipstix can be used to look for signs of infection or diabetes. • Urine drug tests can be used to look for signs of illicit drug use.
Blood tests
• Full blood count • Malaria screen • Typhoid screen (the Widal test) • Urea and electrolytes (U&Es) • Liver function tests (LFTs) • Random blood glucose (RBG) • Thyroid function tests (TFT) • Calcium and phosphate levels • Inflammatory markers (ESR or CRP) • Vitamin B12 and folate levels • Syphilis serology • HIV testing
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Other tests • Alcohol breath test
Often these tests are not available, it is therefore especially important that health workers do their physical examinations in as much detail as possible.
Remember that tests only tell you what is happening to the person at one point in time. It is always better to repeat your physical observations and examination than to rely on a laboratory test that is several days or weeks old. For example a malaria blood test that shows normal results but is 2 weeks old is no good if the person you are seeing has all the signs of malaria (headache, fever, bitter taste in the mouth, abdominal pain and diarrhoea). Remember, the person could have developed malaria since the blood test was taken! If you do not treat the person for malaria because they have a normal blood test and they do actually have malaria then the person could die. Therefore a good saying is ‘always treat the patient in front of you, not the laboratory test’.
2.6 Getting the whole story
Always try and do this. Ask the person you are assessing if it is okay for you to speak to someone who knows what has been going on. This will show the person that you respect them and will make it easier for them to trust you. If they are not happy, explain that it will help you to do your job which is to help them as best as you can.
If you can speak to a member of the person’s family, their carer or a close friend, you should try to ask them many of the same questions you asked the person you are assessing. This will help you to get the whole story. Remember, if you are worried about any of the answers a family member gives to these questions, contact a senior colleague for advice (see your crisis plan on who to speak to).
Assessing a person with mental illness can at first seem like a long and difficult process. However with practice the steps above will become easier allowing you to assess people safely and quickly. In order to save lives always remember the four most important parts of any assessment: • Medicine allergies • Recent physical illness • Safety questions • The physical health check
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CHAPTER 3 Treatments for mental illness
Our brains are very complicated. Therefore mental illness is a complicated subject. We can get an idea of how complex the brain is by comparing it to the heart. The heart sits in our chest and everyday does its job, happily pumping blood around our bodies. If there is a problem with our heart we can give it medicine to make it pump better and that is usually the end of the story.
However, our brains don’t just sit in our heads doing one job. They take in information from the world around us. The brain then reacts to this information in many ways that affect the way we think, the way we feel, how we see the world and how the rest of our body works. If pleasant things are happening around us the brain will react to this and make our bodies and minds feel good. However, if stressful things are happening around us, our brains will make our minds and bodies feel bad. To make things even more complicated the brain can also get into habits where it gets used to feeling bad even though nothing bad is happening around us.
We can now begin to see how complicated the brain is and how complicated the situation can be when we suffer from mental illness. However, do not despair! Mental illness can be easily treated as explained in chapter 1. There are three ways to get people better:
1. MEDICINES (also known as biological or pharmacological treatments). These correct the levels of chemicals in our brain. 2. TALKING CURES (also known as psychological treatments). As human beings we feel better when we talk to other people about what is happening to us. Talking cures help our brains learn to cope with the stressful things that are happening to us. 3. BUILDING THE BEST LIFE POSSIBLE (also known as social treatment). This involves actually changing the world around us so that our lives become easier and less stressful.
Studies have shown that people with mental illness do better when all three types of treatment are used. Let’s look at each treatment in turn.
3.1 Medicine (biological treatment) There are many different medicines for mental illness. We will look at the correct medicine for each type of mental illness in more detail in chapters 5 to 14. At the end of the manual there is also an appendix that contains information for qualified professionals who prescribe medicines. The appendix explains how to prescribe medicines safely as well as manage the possible side-effects. 24
A side-effect is a symptom caused by a drug. Although drugs are prescribed to make us better, many also cause other unwanted symptoms such as headache or stomach problems.
If you able to prescribe medicine, you should always speak to the person about the side-effects of the medicine they are taking and how much the medicine costs. Often the cheapest medicine has the most side-effects. Sometimes a person may wish to take a medicine with more side-effects if it means they can afford to keep taking it.
3.1.1 The golden rules of mental illness and medicine
Stick to the lowest dose . Medicines for mental illness are powerful drugs. Always start on the lowest dose possible. Try to keep the person on the lowest dose possible. Higher doses of medicines often make people more sedated and do not treat mental illness any more effectively than a lower dose. Never give more than the maximum recommended dose (appendix 1 ).
Always use one medicine rather than two . Medicines for mental illness can have complex interactions with each other, this can lead to potentially dangerous side-effects. When possible, people should be treated with one medicine rather than two. Exceptions to this rule include; the short period of time when one medicine is being gradually changed to another and people with epilepsy or bipolar mood disorder who have not responded to an initial course of treatment (see sections 5.2 and 8.2 ).
Patience is a virtue . Medicines for mental illnesses do work but they take longer to work than those for physical illnesses. The person, their family and you need to be patient! Often it can take four to six weeks for medicine for mental illness to start working. In most cases you should wait at least two weeks before deciding to increase a dose of medicine.
The dose that gets you well, keeps you well . Nearly all the medicines for mental illness in this manual are for long-term use. People need to keep taking their medicine as instructed at the same time every day for mental illness to stay away, even if they feel better. Compare mental illness to a condition like high blood pressure or diabetes. A person with diabetes can feel well today but if they do not take their treatment, they will get ill in the future. It is the same with mental illness. Once someone has got better they need to stay on the same dose unless they complain of side-effects. Remember the dose that gets you well, keeps you well.
Don’t stop suddenly . Do not stop medicines suddenly unless you are worried the person is having a severe reaction to the medicine (see chapter 15 and appendix 1 ). If medicine for mental illness is 25
stopped suddenly, a person may feel unwell, they may shake, have lots of mucous in their nose, feel dizzy or have headaches. If somebody wishes to stop their medicine they should discuss this with a health worker to see if anything can be done. If the person still wishes to stop the medicine then it is best to do it slowly over about four weeks. This means the dose of medicine can be gently reduced by one quarter every week.
For each type of mental illness there is a recommended amount of time a person should stay on their medicine once they are feeling better. We will talk about this in more detail in the chapters describing mental illness.
All medicines have side-effects. Therefore use as few medicines as possible. Advice on what to do about the side-effects of each drug is given in appendix 1 . Be careful about adding new medicines as remedies for side-effects, these remedies will have side-effects of their own. In general if a person is having side-effects reduce the dose of medication. If this does not work, change the medicine to another that has fewer side-effects. For example, in psychosis the medicine olanzapine has less side- effects than chlorpromazine or haloperidol.
If a person still has side-effects after reducing the dose of medicine or changing to another medicine, then it is reasonable to try a remedy medication for the side-effects. Always review whether a person needs to take additional medicine for side-effects regularly.
Only use medicines that are indicated for the type of mental illness the person has . Sometimes the type of medicine a person has been taking may become unavailable. If this happens, make sure the new medicine that is prescribed, is indicated for their illness. For example, if a person with psychosis (see chapter 7 ) has been taking olanzapine and this medicine is no longer available, then they need to be started on another medicine that also treats psychosis such as chlorpromazine. Other medicines such as carbamazepine should not be given just because they are available. They will not help the mental illness and will most likely only result in the person having unpleasant side-effects. When changing a person from one medicine to another, remember to start the second medicine at the lowest possible dose and gradually increase the dose over time. Even though a person has been on a high dose of one drug, they will still be sensitive to the side-effects of another.
Some medicines should not be mixed. People should always take their medicine with them when they go to see any doctor or pharmacist. Sometimes different medicines can react together, so it is important that other health workers know what medicines someone is taking for mental illness. Also, some medicines for physical illnesses can cause mental illness like delirium or depressions (see 26
section 5.1 and section 8.1 ). If the person is taking lots of medicines it is a good idea to speak to a doctor or pharmacist.
If you have a copy of the BNF (British National Formulary) you can check in appendix 1 of this book where it lists the interactions of most medicines. The BNF also lists the side-effects of all medicines.
Some medicines should not be taken when pregnant or when breast feeding. Some medicines for mental illness can be harmful to unborn babies or infants being breast fed. This is very much the case for medicines used for epilepsy and bipolar mood disorder / manic depression. Make sure you speak to any woman of child bearing age about this. They will be able to have children if they are on medicine for mental illness; however they need to consult a specialist doctor first. See chapter 10 for more information on giving medicines to women who are pregnant or breast feeding.
Medicines for mental illness should not be used in children. Except when given by experienced mental health specialists such as child psychiatrists. The only exception to this is epilepsy. See chapter 12 for more information on young people and mental illness.
Physically weak people. Always be careful when prescribing medicine to people who are physically weak such as those who are over 65 years old or who have a serious physical illness. See chapter 13 for more information on mental illness and old age.
Avoid alcohol when taking medicine for mental illness. People with mental illness should not drink alcohol. This is because alcohol can make mental illness worse. Medicines for mental illness can also cause drowsiness. This drowsiness can get worse when medicine is mixed with alcohol which can lead to falls or accidents.
Drinking, driving and taking medicine. Never drink alcohol, take medicine and drive. This is very dangerous . It can make a person drowsy and lead to accidents.
Line your stomach. Always try and take your medicine with some food and water if possible.
Medicine should be used when: • You know what type of mental illness the person has, so that you can provide the correct medicine. 27
• A person has a serious mental illness such as an organic mental illness or psychosis . (see chapters 5 and 7). • The person has a common mental illness that has not improved despite psychological treatment and social treatment for four weeks.
Medicine should not be used when: • The person and their family simply expect it after seeing a health worker. As a health worker you will eel under a lot of pressure to give medicines after every assessment. Sometimes you may feel that it is a good idea to give a medicine ‘just in case’. Do not do this! Medicines for mental illness are powerful and should only be given if there is a good reason. Medicines for mental illness are also a valuable resource and should not be given unless people have a definite illness. • Avoid giving vitamin injections for things like tiredness unless blood tests have shown the person to have low vitamin levels. It is much better that a person eats good food to get the vitamins they need.
If a person does not improve after taking medicine: • Make sure the person has been taking the medicine. Often people with mental illness stop medicine after a few weeks because they start to feel better. • Check the person has been taking the medicine for long enough. • Make sure the person is taking the correct dose of medicine. • Make sure the person is not still using alcohol or illicit drugs which will stop them from recovering. • Make sure the person does not have a physical illness that may appear as a mental illness (see section 5.1 ). • Make sure you know what type of mental illness the person has. If you have made a mistake the person may not be on the correct type of medicine. You can always ask a senior colleague to do an assessment on the person to check this.
3.2 Talking cures (psychological treatment) Some people do not think that talking is a ‘proper’ treatment. However research has shown that talking to other people has a real healing effect. It is also free and does not have any side-effects! Ways of talking to people that provide healing involve: • Showing warmth. This is speaking to the person in a friendly manner. 28
• Showing empathy. Showing you understand how the person feels. • Showing positive regard. This means treating the person with respect and supporting them.
These three things are also known as the therapeutic alliance . It is nice to know that by simply being warm and supportive to people with mental illness you are helping them to get better! There are lots of different types of talking cures. Here are some types that you may find helpful.
3.2.1 Counselling This involves spending time with a person and listening to their worries. It is helpful to provide reassurance to the person and an explanation about what is happening to them. It may be helpful to go through the information covered in chapter 1.
People with mental illness can have counselling in groups. This is known as group therapy. It can be very helpful because the person can learn from other people who have had the same problem. If there are no groups in your area for people with mental illness then it is a good idea to speak to a senior colleague about setting a group up. You can contact your local BasicNeeds office for more information on how to do this.
3.2.2 Problem solving work A person with mental illness needs to learn how to deal with the problems in their life. You should not tell them what you think are the answers to their problems. Instead you can teach them how they can come up with answers themselves. This can stop them from getting unwell again in the future. Often a person’s life will have so many problems it can seem like a big mess. To help a person learn to sort out this mess you can do the following things: • Ask them to list all the different problems they have. The biggest problem should be number one, the next biggest problem should be number two and so on. If the person can write it may be helpful to write the list. • Ask the person to think of ways to tackle their first problem. If the answer looks complicated, ask the person to think of lots of small steps they can take that could help. If possible, write these steps down as a plan for the person to follow. • Agree a time for when you will meet with the person again and check they have followed the plan. If the plan has been a success, move on to another problem in their life and do the same thing. If the plan has not worked, explore why it has not worked. Remind them that this can be seen as important progress as it is helpful to learn what works and what does not work in life. Then come up with a different plan, follow it and meet again to see if it works. Keep going until you find a plan that works.
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Here is an example A 27 year old man called Derry from the Upper West Region has a lot of stress because he has no money. His life seems to be a big mess and he does not know what to do.
A BasicNeeds volunteer asked Derry to list his problems. They were: 1. Not having enough money to buy food 2. Owing his friends money 3. Not having a girlfriend. The volunteer encouraged Derry to look at problem number one first, as it was the biggest problem. Derry knew he needed a job to get money. However he didn’t know how to get a job. He felt finding a job would be too complicated because his life was a mess. The BasicNeeds volunteer asked him to think about what a person needs to do to get a job. Derry felt that a person needs to be smart and presentable to get a job. An employer also needs to know a person is reliable before they give him a job. The volunteer helped Derry think of the small steps he needed to take in order to get a job. Derry came up with the following plan:
Step 1 In order to look clean and respectable Derry would wash and shave at a friend’s house. He would also borrow clean, smart clothes from his friend.
Step 2 Derry thought about local people that he could go to and see about giving him a job.
Step 3 In order to show employers he was reliable, Derry felt it would be a good idea to offer to work for free for a morning. This would allow him to show he was a hard worker. He would then offer to work for food for a few days. After that he would ask to be paid money.
Step 4 Derry and the BasicNeeds volunteer agreed to meet in one week to see if the plan had worked.
One week later Derry and the volunteer met again. Derry went to five shops asking for work. The first four employers said no but at the fifth shop the owner agreed to give him a trial. Derry worked so hard the shop keeper decided to offer him a job. Because the plan worked 30
Derry and the BasicNeeds Volunteer agreed to repeat what they had done in order to find ways to sort out his other problems.
3.2.3 Relaxation and breathing work This is a very useful way of helping someone deal with stress. Ask the person to do the following things: Find the quietest place possible. Formatted: Bullets and Numbering Lie or sit down in a comfortable position. After about 10 seconds concentrate on their mind and their breathing. Concentrate on taking slow, regular breaths through the nose. Breathe in whilst slowly counting to three and then pause. Slowly count to three whilst breathing out and then pause. Keep breathing in and out whilst slowly counting to three and pausing. Once the breathing is nice and slow the person should imagine pleasant words every time they breathe out. The words can be anything that makes the person feel relaxed. For example someone who is religious may think “God is with me”. Even imagining the word “relax” whilst a person breathes out can be very useful. Once they are comfortable breathing slowly and imaging pleasant words they can then use their imagination to see things that are pleasant in their minds. Once again they can imagine anything that makes them feel relaxed. Examples of things people often imagine include a pleasant colour covering their body in light, being with a person that makes them feel safe (this can be a real or imagined person), being in a situation where they feel happy (such as being on the beach or at a family gathering). Do these steps for at least 10 minutes every day.
These steps can be thought of as exercises for the mind. Like physical exercise for the body they can be hard at first! However the more these exercises are practiced the easier they become and the stronger the mind will get at dealing with stress. Most people feel the benefits after about two weeks of doing the exercises for 10 minutes every day.
Try these exercises yourself. You do not have to have a mental illness for them to do you good! It is then helpful for you to show people how to do the breathing properly. Fact sheet 3 will also explain how to do the exercises; you can photocopy this and give it to people.
3.2.4 Crisis planning 31
With each person you see it is helpful to come up with a plan for what they and their families will do if there is a crisis. Follow the same steps as you did at the start of this manual when you worked out your own crisis plan. Think of who they will contact and what they will do if there is a ‘worst case scenario’. Fact sheet 1 has a crisis plan you can copy and give to the people you see and their family. Make sure you explain clearly that this plan is to help them and keep them safe in a situation where they don’t know what to do.
3.2.5 Coping strategies Coping strategies help to take someone’s mind away from the bad things that are happening to them. • Ask the person to think of a pleasant activity, for example: talking to other people, listening to music or watching television. • Ask the person to list as many of these pleasant activities as possible (try and get at least five). • Then ask the person to list these activities with the most pleasant being number one and so on. • Ask them to make a plan of how they will use the activities next time they are feeling bad. • Agree a time for when you will meet again to see if the plan has worked. If the plan has worked congratulate them as they are starting to make progress! If the plan has not worked, explore the reasons why. Remind them that this can also be seen as important progress as it is helpful to learn what works and what does not work in life. Then come up with a different plan, follow it and meet again to see if it works. Keep going until you find a plan that works.
Here is an example: Mame Abena is a 32 year old lady from the Ashanti Region. She has been feeling very bad. She has been seen by a mental health worker who has diagnosed her with depression. The worker has explained that it may take up to four weeks for her medicine to start working. Mame wants to find a way to feel better whilst she is waiting for the medicine to start working. She often feels worst in the mornings for several hours. The mental health worker helped Mame come up with the following plan.
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Mame is feeling bad
Step 1 Mame should play with her children for at least 30 minutes. Often when she plays with her children they will make her laugh after about 10 minutes. This can make her feel better. However if she does not feel better after playing with her children for 30 minutes she should go to step two of the plan.
Step 2 Mame should go and see her neighbour Esi Atta. Often Mame feels better after talking to her neighbour for about one hour. However, if Mame does not feel better after this she should go to step three of the plan.
Step 3 Mame should play her favourite record by her favourite artist Kojo Antwi. She normally feels better after listening to five of his songs. However if she doesn’t feel better after this she should go to step four.
Step 4 Mame should try and do some cleaning. This is often good at taking her mind off her troubles. It usually takes her about 30 minutes to forget about her troubles and start concentrating on her work. However if she doesn’t feel better after this she should go to step 5 of the plan.
Step 5 Mame should sit down and relax and think of something nice.
Mame and her mental health worker met up again after one week to see how the plan had worked. Mame used the plan each day. She felt it didn’t work for the first two days but by the third day she found that she felt better by the time she finished cleaning. By the fourth day she felt better when she was listening to music and so she didn’t need to do the other steps on the plan. Mame agreed to keep using the plan as well as taking her medicine. 33
Coping strategies are very powerful because they teach a person with mental illness how they can start dealing with what is happening to them. This means that they start being in control of their lives.
3.2.6 Different ways of looking at a situation Sometimes people with mental illness feel that it is impossible for them to ever get better. They can also feel that it is impossible for their situation to ever change. There are some helpful exercises you can do to help people look at a situation differently.
Exercise 1 • Ask them to imagine that their brother or sister is in the same situation as they are. • Get them to think about the advice they would give to their brother or sister. • Ask them to be as honest as possible. They have to really try to imagine the very best advice they would give. The advice can even be something as simple as “everything is going to fine in the end, it always is”. • Provided the advice is sensible ask the person why they themselves do not take the same advice they would give their brother or sister? Surely none of us would like to think we deserve different or better advice than our brother or sister! • Get the person to remember this advice every time they feel bad. They need to learn to believe and follow the same advice they would give their brother or sister at all times.
Exercise 2 This exercise requires the person to write on a piece of paper. If they can not read or write, ask them to memorise the written part instead. • Draw a line down the middle of a piece of paper. • On one side of the line get the person to list all the bad things in their life (ask them to memorise the list if they can not write). • On the other side of the line ask the person to list all the reasons why their life is good – they may need some help with this. Ask them to think of the opposite of any bad reason they have put down. For example: a person may have written that their life is terrible because no one cares about them. On the good side of the paper you should list all the brothers and sisters they have who do care about them. • You should the paper (or remember the list) at least twice a day to remind themselves that things are not as bad as they may think. 34
• You can come up with a plan with the person so that they do more of the GOOD things in their life. For example they can speak to their brothers and sisters more often if they feel no one cares about them. • You can also come up with a plan so that there are less of the BAD things in the person’s life. The problem solving work that we covered earlier in this chapter is very helpful for this.
3.3 Building the best life possible (social treatment) When someone becomes mentally ill they may need a few weeks rest. After this time it is important for them to start rebuilding their life. It has been shown that for people with mental illness to get better and stay well they need to have the correct balance in their lives.
In order to get the right balance in a person’s life it is important to speak to them about how they would like their life to be in the future. This is known as the person’s goals . It can be very helpful to write down the person’s goals so that you both know what kind of life they would like in the future.
3.3.1 How to rebuild a person’s life In order to help rebuild a person’s life – think about how they should spend their time. • Daily Routine. Work out what they will do each day. Do not forget their basic needs! Before they go any further in rebuilding their life, they need to be able to wash themselves, dress themselves, feed themselves and take their medicine. • Sleep . It is very important that people who have had a mental illness go to bed and get up at regular times. In the past people with mental illness used to be given sleeping tablets. However modern research has shown that these do not work in the long-term and are addictive. They should only be used in an emergency and only for up to two weeks. There are better ways you can help people who have problems sleeping. There are a set of exercises called sleep hygiene exercises that have been shown to work. Fact sheet 2 explains how to carry out these exercises. You can copy this fact sheet and give it to anyone who is having trouble sleeping. 35
• Diet. It is important that people with mental illness eat good healthy food regularly. • Exercise. Research has shown that exercise helps people with all types of mental illness. It really is true that a healthy body can lead to a healthy mind! Exercise can start in lots of simple ways. For example cleaning and walking are both types of exercise. • Socialising and pleasant activities. It is important that people with mental illness begin to gradually start seeing their family, friends and people in their community. Doing this and taking part in pleasant activities shows a person that they are really starting to rebuild their life after mental illness. Once again research has shown that these things help people get better from mental illness. • Work . As covered in chapter 1, nearly everyone with mental illness can do some kind of job and be useful to their family. It is a great waste that people with mental illness often lose their jobs. Research has shown that people who have had a mental illness can work. In fact, keeping busy can stop mental illness from coming back.
Even if a person did not have job before they became mentally ill you should still encourage them to do things that help their family. For example they could help another family member in their job. This will show the person with mental illness that they are useful and this will help them get better.
3.3.2 Working with a person’s family Mental illness can be very upsetting both to the person who is unwell and their family. It is very common for members of a family to feel ashamed, angry, guilty and frightened. Take time to speak to the family of every person with mental illness that you help. If a person’s family understands their illness – this will help them to get better and stay better.
How to explain mental illness to a family The following are things that need to be made clear to every family you meet: • Mental illness is nobody’s fault. • We do not think that mental illness is caused by witchcraft or spirits. • Mental illness is not infectious and will not be caught by touching the person who is mentally ill or sharing their food. • Mental illness is treatable. • People with mental illness can lead a normal life with some adjustments. They can marry, have children and work in most types of job. Great people throughout history such as 36
Winston Churchill (a British Prime Minister) have had mental illness but still did great things with their life. • The person who has had a mental illness is exactly the same person as they were before they became unwell. • Speak to the family about their spiritual beliefs. Many people think that it is wrong or goes against their spiritual beliefs to take medicine or treatment for mental illness. Research has shown that having spiritual beliefs can help people to get better from mental illness. However it makes no sense for people not to take the right medicine because they are worried it is against their spiritual beliefs. Always respect the beliefs of others but politely explain that treatment for mental illness can usually be seen as acceptable to any person’s religious beliefs. The following is an explanation that may be useful.
Most people would agree that God or a higher spirit has blessed mankind with intelligence. Most would also agree that God wants us to use this intelligence wisely. An example of using this intelligence wisely has been man making plumbing, pipes and taps so that we have water to drink even when it does not rain. Though lots of people pray to God for rain we must all agree it would be foolish not to use the plumbing, pipes and taps we have to get water if it does not rain. Most people would agree that God does not want our family to die of thirst if there is no rain but we can get good water from the taps!
It is the same with mental illness! God has blessed mankind with the intelligence to understand mental illness. God has also blessed mankind with the intelligence to discover good medicines for mental illness.
Though it makes sense to pray for good mental health surely it also makes sense to use the medicines that we have already been blessed with? If we do not use the medicines that work for mental illness surely we are like someone who lets his family die of thirst because he doesn’t believe the water in the taps comes from God?
Managing stress Make sure the family of a person with mental illness understands they have a very important job to do. They can help their relative with mental illness get better and also help them stay well. Two of the most useful ways are managing stress and relapse prevention. One of the best ways of managing stress is to ensure the family helps their relative to get the right balance in their life. The table at the beginning of this section 3.3 explains why this is so important. 37
Three other things have been found to be important in managing stress in people with mental illness. • Critical comments. This is when people say unpleasant things to someone with mental illness. Examples would include calling someone lazy, shameful, mad or good for nothing. • Hostility. This is when people raise their voices or shout at people with mental illness. • Over involvement. This is when people interfere too much in the life of someone with a mental illness. The person with a mental illness feels like they do not have any freedom.
These three things are called expressed emotion. They make a person become more stressed and lead to them becoming unwell again. Research has shown that we can stop nearly half of people with serious mental illnesses like schizophrenia from becoming unwell again by stopping expressed emotion. To stop expressed emotion, do the following things: • The family should encourage the person to do things that they are good at rather than pointing out the things they do that are bad. • The family should avoid getting very angry or shouting at the person with mental illness. • The family should allow the person with mental illness to have freedom to do things they want to do. • They should also let the person with mental illness make decisions about how they would like to rebuild their life (provided these decisions are safe). • If the family are religious, point out that having spiritual beliefs can be helpful in keeping someone well. Sometimes very loud religious activity can lead to a person becoming too stressed and unwell again. However calming religious activities such as quiet prayer and meditation can be healing.
3.3.3 Relapse prevention This is where a person with mental illness and their family thinks about what happened when the illness started in order to stop it from happening again in future.
It can be helpful to think with the person and their family about the things covered in chapter 1: • What happened before the mental illness started? • What happened when the mental illness started? • What happened after the mental illness began?
You can then try and work out if something changed as the person became unwell: • Did they suddenly have a lot of stress in their life? • Did they have problems sleeping? 38
• Did they feel as though things were not quite right? • Did they stop taking medicine?
These things are early warning signs that a person is becoming unwell. If a person gets help as soon as they see any early warning signs, it can prevent them from becoming seriously unwell again. It is a good idea to write down a person’s early warning signs as well as whom to contact for help. Give a copy of this plan to the person and their family. 39
CHAPTER 4
The different types of mental illness
There are lots of different types of mental illness. It is helpful to think of the different types of mental illness as a pyramid. The most serious types of mental illness are at the top of the pyramid whilst the less serious are at the bottom.
The types of mental illness listed in the top three sections of the pyramid are called the severe mental illnesses. It is difficult for most people to understand what is happening to a person with a severe mental illness because it is strange and unusual. The types of mental illness listed in the bottom two sections of the pyramid are called common mental illnesses. Common mental illness is like an extreme form of something we all experience like sadness or worry. Therefore people can usually understand what is happening to the person. Most of the mental illness you see will be common mental illness (mood disorders and anxiety disorders).
The types of mental illness at the top of the pyramid are less common but more serious. You always need to think about the types of mental illness at the top of the pyramid when you first see 40
a person. Not recognising or treating the illnesses at the top of pyramid will have the most severe consequences.
It is good to work down the pyramid when you first see someone with a mental illness. Firstly find out if the mental illness could be due to a physical illness (an organic mental illness). If this is not the case then think if the mental illness could be due to alcohol or illicit drugs (a substance misuse mental illness). If this is not the case keep working down the pyramid until you find the type of mental illness you think the person has. This approach will mean that you are unlikely to miss a severe mental illness.
The types of mental illness at the top of the pyramid can also cause the types of mental illness at the bottom of the pyramid. This can lead to very complicated situations where a person has several types of mental illness at once! However, do not panic! The most important thing is to first treat the mental illness that is highest up the pyramid. When this is treated, often the other types of mental illness get better as well. For example:
Kwame Agyeman Bedu was a 34 year old man from the Ashanti Region. He was seen by a BasicNeeds volunteer because he was feeling very sad and not sleeping well. He was also feeling very worried all of the time. To cope with how he was feeling he was drinking lots of akpeteshie every day.
In this example Kwame is drinking too much alcohol. This is substance misuse . Kwame is also sad and unhappy. He also has depression, this is a mood disorder . Kwame is also feeling very worried.
This sounds like an anxiety disorder . The situation seems very complicated. However the BasicNeeds volunteer knew that substance misuse was highest on the pyramid of mental illness and so was the most serious problem.
The BasicNeeds volunteer advised Kwame to drink a little less alcohol each day for a one week. After this time he advised him to stop drinking alcohol completely. Kwame and the BasicNeeds volunteer met again in two weeks time. Kwame reported that his sleep had gone back to normal. He was not feeling sad anymore and he was also starting to feel less worried.
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We will cover the treatment for substance misuse in more detail in chapter 6 . In the next few chapters we will look at the different types of mental illness in more detail. Each chapter will look at different sections of the pyramid. 42
CHAPTER 5
Organic mental illness
5.1 Delirium Delirium is another term for confusion due to physical illness. Delirium is very common in Ghana. This is because serious physical illnesses like malaria, typhoid and chest infections are very common. A large number of people that you will assess for possible mental illness will actually have a physical illness that is making them unwell. Delirium is the most serious type of mental illness you will see. This is because a large number of people with delirium will die if the physical illness that is causing it is not quickly and correctly identified. You should always suspect delirium in a patient who presents with confusion or drowsiness.
What are the key features of delirium? • The person may not be fully conscious. • You may feel they are not completely aware of you. • The person is disorientated. This means they may not know what time it is, where they are or who they are. • The person will not be able to sleep. • The person behaves in an odd or strange way. • The person may be restless, aggressive, suspicious or fearful. • The person will not be able to remember things. • The person will not be able to concentrate on things that are happening to them. For example they may not be able to concentrate on what you are saying to them. • They may see or hear things that other people cannot. These are called visual and auditory hallucinations. Visual hallucinations are strongly suggestive of delirium.
All of these features begin very suddenly. They also become better or worse in minutes or hours. Typically all the key features of delirium get worse at night.
Who gets delirium? Anybody with a physical illness can get delirium. Delirium also tends to be more common in people who are more likely to become physically ill for example, the very old or very young.
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What is thought to cause delirium? Delirium is caused by any physical illness. Common causes include: • Not having enough fluid in the body (dehydration). • Any fever or infection. For example malaria, typhoid, chest infections, urine infections, meningitis or HIV. • Abnormal levels of salt or sugar in the body (diabetes). • An injury to the head. • Being drunk or high on illicit drugs. People who drink a lot of alcohol and then suddenly stop can also get delirium. (See chapter 6 ). • Side-effects from medicine. This can be common in older people.
Questions to ask during your assessment? The person with delirium will probably be too confused to tell you what has happened. So, make sure you speak to other people who know what has been going on. Find out how long the problem has been going on for – someone with delirium becomes unwell over hours or several days. If a person has a mental illness like dementia or psychosis (where they can also act strangely) they become unwell over a much longer time; weeks or months in the case of psychosis (see chapter 7 ) and months in the case of dementia. Always ask about recent physical illnesses in a person who is drowsy or confused (see section Formatted: Bullets and Numbering 2.3 for what questions to ask). Make sure you find out how much alcohol the person uses or if they use illicit drugs. Find out when Formatted: Bullets and Numbering they last drank alcohol or used illicit drugs.
Things to look for and to do during your assessment Make sure you test for confusion and do a physical health check ( see 2.4 and 2.5 ). Formatted: Bullets and Numbering If possible check the person’s blood sugar level. If this is low then give them a sugary drink at once.
What is the treatment for delirium? The person needs to be taken at once to a health worker who can find out which physical illness is causing the delirium. The physical illness needs to be treated immediately (before the mental illness). This may mean the person has to go to hospital (see your crisis plan). The correct treatment for the physical illness will make the delirium better.
In general, emergency treatment for physical illness consists of five things: Monitoring physical observations (temperature, pulse, blood pressure, respiratory rate and Formatted: Bullets and Numbering capillary refill). Giving the person enough fluids. Giving paracetamol if the person has a high temperature. 44
Treating any infection. Lowering the dose of most medicines for mental illness apart from those used for epilepsy (see appendix 2 ).
Steps 1–3 can be done by anybody. Appendix 2 explains all of these steps in more detail and can help you save the life of someone with delirium. These steps can be followed whilst the person is being moved to a hospital or if there are no senior health workers available.
Whilst the physical illness is being treated the person needs to be: • Kept in a quiet room away from loud noises or excitement. • Reassured, as they may be feeling frightened. • Reminded of who they are, where they are, what the time is and what has happened to them. • Cared for by one person (if possible). This will help them feel less confused. If a nurse is not able to do this then a family member can do this job.
If the person is aggressive and agitated after doing the things already mentioned above, you may have to give them some medicine such as haloperidol to calm them down. Remember to give the lowest possible dose of sedative medicine. Chapter 16 has more information on how to manage violence and aggression.
Once a person begins to improve, they may need counselling afterwards as they will not know what has happened to them (see section 3.2 for more details about counselling).
What next? Delirium usually lasts for less than one week. People with delirium get better very quickly (usually within a few days).
Talk to the person and their family about what happened when they first became unwell. This will help you find out what the early warning signs were so you can put together a plan to stop delirium happening again (see section 3.3.3 ).
Further reading Any good medical reference textbook will be able to give you more information on delirium.
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5.2 Epilepsy
Everybody’s brain uses tiny amounts of electricity to do its job. Epilepsy is caused by abnormal surges of electricity in the brain. These surges of electricity cause epileptic seizures.
What are the key features of epilepsy? There are three types of seizure. i) Generalised seizures : Here the person becomes unconscious. The person having a generalized seizure may also: • Fall down. • Bite their tongue (this is very suggestive of epilepsy). • Become very stiff and shake. • Their eyeballs may roll upwards. • Froth at the mouth. • Pass urine or faeces. • Their lips may become blue and pale. • They may feel drowsy and confused after the seizure and have no memory of what has happened. ii) Partial seizures : Here the person is awake but is not aware of their surroundings. Partial seizures can be difficult to detect and can involve any of the following things: • They may have a feeling that something strange is going to happen, this is called an aura. It may involve an unusual feeling in the stomach. Or they may smell, see or hear strange things. • Τhey may have jerky movements in one part of their body. • They may smack their lips. • They may perform a series of repeated movements. • Sometimes a partial seizure can go on to become a generalised seizure. iii) Hysterical or conversion seizures : Unlike the other two types of seizure, this type of seizure is not caused by abnormal surges of electricity in the brain. They are caused by stress. The person may fall to the ground and shake but they: • Do not have all the features of the other two types of epilepsy. In particular there is no tongue biting or passing of urine and the lips will not go blue. • These people do not become unconscious.
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Who gets epilepsy? About one in every 100 people around the world are affected by epilepsy. Most often epilepsy starts in people under the age of 30. Epilepsy is more common in men and people with mental retardation.
What is thought to cause epilepsy? In most cases the cause of epilepsy is unknown. However important causes of epilepsy are: • Withdrawal from alcohol (not to be missed!) or intoxication from illicit drugs. • Infections (often due to HIV or malaria but any infection can cause it). • High or low levels of salt or sugar in the body. • Problems inside the head such as bleeding or cancer. • Delirium.
Questions to ask during your assessment • The most important thing to do is to speak to someone else who has seen the seizure. This is because the person who has had the seizure will not remember everything. You need to get a clear picture about what happened. A witness will be able to help you decide if this is epilepsy, and if so what type of seizure the person has been having. • Ask about any recent physical illness (see section 2.3 ). This is especially important if the epilepsy has recently become worse. • Make sure you find out how much alcohol the person uses or if they use illicit drugs. Find out when they last drank alcohol or used illicit drugs. Seizures caused by alcohol and illicit drugs are covered in more detail in chapter 6 .
Things to look for and to do during your assessment • Make sure you test for confusion to check to see if the person has delirium. • Make sure you do a physical health check (see section 2.5 ). • If the person has just had a seizure, check the person’s blood sugar level if possible. If this is low then give them a sugary drink at once.
If you find the person has delirium or a physical illness follow the advice given in section 5.1 . Everybody should be physically checked over by a senior health worker after their first seizure. This is especially important for people who had their first seizure after the age of 30 as their epilepsy is more likely to be caused by a physical illness.
Make sure the person had a seizure and did not faint Faints are different from seizures in the following ways: • Seizures start suddenly and faints are gradual. 47
• A person is usually unconscious for minutes with a seizure but is unconscious for seconds with a faint. • Biting the tongue, passing urine, jerking movements and the lips turning blue are seen in seizures. They are not seen in faints. • A person who has had a seizure is confused for at least a few minutes and has no memory about what happened. Someone who has a faint recovers within a few moments and has little confusion.
If the person has had a faint, advise them to try drinking more water and to get up slowly from lying or sitting down. It may be worth them seeing a general doctor for a check-up.
What to do if someone has an epileptic seizure Take a deep breath and don’t panic! You will be able to do something to help this person but you need to be calm and focused. Do the following things: • Remove anything that may harm them. For example nearby heavy objects and electrical equipment. • Roll them onto their side. • Remove anything that may stop them from breathing. For example they may have food in their mouth (don’t get bitten). • Loosen any belts or ties. • Do not try and restrain them. • Do not try and put anything in their mouths including food, water or medicines. • Wait for 5 minutes (most seizures finish on their own during this time).
If a seizure lasts for more than five minutes • Get someone to call for medical assistance (see your crisis plan for who to contact) • If you are trained: i. Insert a plastic airway. ii. Inject 100mg of thiamine into a vein followed by a solution of 50% dextrose. iii. Then inject 10mg of diazepam (also known as valium) into a vein slowly over about two minutes. iv. Wait for another 5 minutes. v. If the seizure is still continuing, inject another 5mg of diazepam. 48
vi. If the seizure still hasn’t stopped after this, keep injecting 5mg of diazepam every 5 minutes until the seizure has stopped (this is when the person stops shaking) or when you have given the person 20mg of diazepam. vii. If the seizure is still going on after you have given 20mg of diazepam keep the person rolled on their side and wait for a doctor’s advice. viii. Throughout this time monitor the person’s breathing rate. It can be easier to get someone else to do this if you are busy doing other things like preparing medicine. If the breathing rate becomes low (below 12 breaths per minute) do not give any more diazepam. Wait until a doctor arrives before giving anymore medicine.
After a seizure has finished or when you are asked to see someone about a seizure they have had in the past, make sure you do a full assessment.
Long term treatment of epilepsy: Medicine (biological treatment) Medicine is not usually started after the first seizure. However a person needs to be on long-term medicine if they have had two or more generalised or partial seizures. The medicines used to treat epilepsy are sodium valproate , carbamazepine , phenobarbitone and phenytoin . If available, sodium valproate is the best medicine to treat generalised epilepsy and carbamazepine is the next best choice. Carbamazepine is the best choice of medicine to treat partial epilepsy. Each of these medicines have potentially serious side-effects (particularly phenytoin). Appendix 1 provides more information on the side-effects of these medicines, how to manage them and how to take the medicine.
Medicine is not given for hysterical / conversion seizures which are due to stress. If you think the person is having hysterical / conversion seizures, consult a senior colleague for advice about what to do next (see your crisis plan).
Medicines used to treat epilepsy interact with each other in complex ways. Sometimes these interactions can lead to dangerous side-effects. It is therefore always best to treat a person with only one type of medicine if possible. Start with a single medicine and slowly increase it until the maximum dose is reached. If this does not control the seizures, start the second most appropriate medicine at its starting dose and withdraw the first medicine over at least 6 weeks. The second medicine should then be slowly increased until the maximum level is reached. Only consider combining two medicines to treat epilepsy if all appropriate medicines have been tried singularly at their maximum dose.
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Remember, these are powerful drugs. Always stick to the lowest dose possible. For more information on what dose to give, see appendix 1.
Do not give a person with epilepsy medicines for other mental illness such as anti-psychotics (Chlorpromazine, olanzapine, haloperidol, trifluperazine) or anti-depressants (amitriptyline), these medicines will actually make the epilepsy worse .
Long term treatment of epilepsy: Talking cures (psychological treatment) Having seizures is very frightening both to the person and those around them. It is important to spend time counselling and reassuring them.
Long term treatment of epilepsy: Building the best life possible (social treatment) People with epilepsy should do the following things: Go to sleep and wake up at regular times. • Eat meals regularly. • Drink as little alcohol as possible. • Avoid extreme physical exercise. • Avoid situations that can lead to sudden excitement or stress. • Avoiding anything that may trigger a seizure, for example flashing lights.
People with epilepsy suffer from stigma and can be kept away from living a normal life. There are some jobs they cannot do for safety reasons such as driving a taxi. However most of the time they lose their jobs because their employers are scared of epilepsy. People with epilepsy can work and can do a good job. It is important to help them find a job, have a daily routine and take part in activities they enjoy.
It can be helpful for the person to keep a diary or record of when they have their seizures. This can help you and the person decide if their dose of medicine is working or if it needs to be increased.
What next? Once the seizures are brought under control, a person will need to take medicine for at least two years or longer, otherwise the epilepsy is likely to come back. If they have been well for at least two years they will then need to consult a specialist doctor about slowly stopping the medicine.
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It is not safe for the person who has epilepsy to drive, operate heavy machinery or swim alone under any circumstances in case they have a seizure. This could lead to either themselves or another innocent person being killed! Write down that you have given this advice to the person.
The medicine used to treat epilepsy is very powerful. Women taking medicine for epilepsy should use contraception and not get pregnant whilst on medicine for epilepsy. A seizure or the medicine could harm their unborn baby. If they do want to get pregnant, they should see a specialist doctor for advice.
See chapter 10 for more information on epilepsy, pregnancy and women who are breast feeding.
Further reading Epilepsy Action have a website with downloadable resources for professionals, carers and people with epilepsy. See their website for details: www.epilepsy.org.uk 51
5.3 Dementia
Dementia is a condition that affects our ability to remember things. It is like a very severe version of common memory loss that affects many people as they age.
What are the key features of dementia? • The person forgets things like the names of their brothers or sisters. • The person becomes lost in places that should be familiar to them. • The person may wander away from their home at night. • The person may become angrier or more irritable than normal. • They may behave in a strange way. • People who have known the person a long time may think they have changed. • The person with dementia may laugh or cry for no reason. • They may stop doing things they used to enjoy doing. • The person may say things that do not make sense. • The person may behave in a way that is inappropriate for them, for example a person who had been shy their entire life may begin speaking openly about sex.
These signs occur over time in people with dementia. This is different from delirium where a person gets confused and acts strangely very quickly. The changes that occur in dementia happen over months or years whilst the changes in delirium happen over hours or days.
Who gets dementia? Dementia usually happens in people over the age of 65. However younger people with HIV can also get dementia.
What is thought to cause dementia? • In most cases dementia is caused by diseases of the brain such as strokes (bleeds inside the head or blood clots), infections (such as HIV) or Alzheimer’s disease (this is where the normal aging process of the brain speeds up). • Having an under active thyroid gland. • Drinking too much alcohol for many years. • Low levels of vitamins such as folate or vitamin B12.
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Questions to ask during your assessment • Speak to other people who know what has been going on. The person with dementia may be too confused to tell you what has been happening. • Find out how long the problem has been going on for. • Find out how much alcohol the person uses or if they use illicit drugs. • Find out when they last drank alcohol or used illicit drugs.
Things to look for and to do during your assessment • Make sure you test for confusion and do a physical health check (see chapter 2 ). • Test the person’s sight and hearing, a basic way to do this is explained in section 12.6. Often older people who have sight and hearing problems can appear to have dementia. If you think the person may have a sight or hearing problem refer them to a specialist.
If you suspect a person has dementia they should be seen by a doctor or a health worker who is able to find out if there is a physical illness causing the dementia (see section 2.5 ). If you suspect a person has dementia then you should also ask someone senior to see the person and see if they agree with you. This is because dementia and depression can sometimes seem to be very similar in elderly people. Depression is a much less serious mental illness than dementia and you should make sure you are treating the right illness.
Treating dementia : Medicine (biological treatment) Medicine can be used when a physical illness has been found to cause dementia. The correct treatment for the physical illness will make the dementia better. If a physical illness is not causing the dementia, then you should try to avoid giving medicines if at all possible. This is because people with dementia are often very weak. That means they can have lots of side-effects from medicine such as dizziness which can lead to falls.
If the person with dementia is extremely suspicious, angry or agitated: • Try and distract the person by drawing their attention to something else. • Try and find out what it is that has upset them, so that this can be avoided in the future.
If these things do not work you may have to give a small dose of medicine such as haloperidol. Once the person is calm, stop giving the haloperidol. Sometimes people with dementia might need to be on a small dose of haloperidol each day to remain calm. However this should only be done as a last resort. You should regularly see what they are like without medicine and stop the haloperidol if they are okay. See appendix 1 for more information on using haloperidol safely. Treating dementia: Talking cures (psychological treatment) 53
People with dementia can be very confused and frightened by what is happening to them. Counselling can be very comforting for these people. Whenever possible treat people who have dementia with warmth and empathy. Speak slowly and clearly. If the person with dementia does not understand what you are saying use simple words and phrases.
Treating dementia: Building the best life possible (social treatment) It is very important to help the person with dementia and their family to build the best life possible. Try and work out a daily timetable for them. Think about and discuss tasks that the person can do each day. Keep the tasks simple and try and let the person with dementia do these things for themselves as much as possible.
Try to think about how you can ensure the person with dementia: • Goes to bed and gets up at the same time each day. • Gets washed and dressed each day. • Uses the toilet regularly and properly. • Does not drink too much fluid towards the end of the day in order to avoid bed wetting. • Eats regularly and is able to eat the food provided. For example it might be necessary to cut up the food into small pieces.
The family of a person with dementia can help them to be safe and less confused by doing the following things: • Making sure the person with dementia has regular sight tests. • Put signs on the doors of rooms so the person with dementia knows where they are going. • Put a sign up every day with the day of the week and date on it. If they can not read, remind them of the day and date regularly. • Make the person with dementia a bracelet with their name, address and the phone number of a family member on it. If they get lost and cannot remember where they live, they can look at their bracelet. Alternatively the family can write this information on a piece of paper. • If the person with dementia wanders frequently, lock the doors of the house to prevent this. • Keep any medicine in a safe place and ask a family member to give it to the person with dementia. • This stops them from forgetting to take their medicine or from taking too many tablets.
What next? In some cases a physical illness causes the dementia. In these cases the dementia will improve when the physical illness is treated. In most cases though, the dementia continues to get slowly worse until the person dies. Dementia can progress to a point where the person may not be able 54
to get out of bed or look after themselves at all. It can take from five to 10 years from the onset of dementia for this to happen. It is important that you are honest with the family so that they can plan for the future.
Though dementia is a very sad illness it can be helpful for a family to know why a person is behaving in a strange way (because the person has a serious mental illness and not because they are a bad person). It is important that the person with dementia and their family enjoy the time they have together.
Further reading The Alzheimer’s Society (UK) provide downloadable resources for professionals, carers and people with dementia. See their website for more information: www.alzheimers.org.uk Alternatively, the Royal College of Psychiatrists provide information on both dementia and other memory problems: www.rcpsych.ac.uk/mentalhealthinformation.aspx 55
CHAPTER 6 Substance misuse
If a person drinks alcohol or uses illicit drugs and it has a negative effect on them or the people around them then we call this substance misuse.
Safe amounts of alcohol to drink • A glass of beer, a glass of wine or a measure of spirits can be thought of as a standard drink. A man is drinking too much if he drinks more than three standard drinks each day or 21 standard drinks in a week. A woman is drinking too much if she drinks more than two standard drinks each day or 14 standard drinks in a week. • These amounts of alcohol should be drunk over the course of the week – not all at once. • Everyone should have at least two days each week when they drink no alcohol. Alcohol should not be ‘saved up’ for a week and then drunk with the next week’s amount! If a person drinks more than these safe amounts, their physical and mental health is in danger.
Illicit drugs If any person uses illicit drugs then their mental and physical health could be in danger. Common illicit drugs include: • Marijuana, also know as cannabis, abuzamtawa or weed which is smoked. • Cocaine which is sniffed or smoked. • Heroin which can be smoked or injected.
Medicines from doctors or pharmacists A very small number of medicines can be misused by the person taking them. The most common example is the person who takes too many sleeping tablets. The steps to take for this problem are the same as those explained below for alcohol and illicit drugs.
What are the key features of substance misuse? There are two patterns to substance misuse: 1) Some people will use alcohol or illicit drugs everyday. 2) At other times a person may ‘binge’. This means they will not drink alcohol or take drugs for a period of time (days or weeks) and then drink a lot of alcohol or take many drugs at once.
After a time a person will need to keep using alcohol or illicit drugs. This is known as addiction or dependency. We can tell a person is dependent when: 56
• Alcohol or illicit drugs become the most important thing in their life. • The person needs to take more and more alcohol or illicit drugs for it to have an affect. This is because the person has become tolerant to their initial intake. • They get tense, shake, feel confused or have seizures when they do not have alcohol or illicit drugs. • This is called a withdrawal reaction. It usually happens when someone has drunk a lot of alcohol for a long time and then suddenly stops. • They will use alcohol or illicit drugs to stop having a withdrawal reaction. • They will keep using alcohol or illicit drugs despite all the bad things it does to them. • They will go back to using alcohol or illicit drugs after stopping for a little while because they feel they can not live without it.
Who has problems with substance misuse? Substance misuse is more common in men and young people. However, you should always remember that women with substance misuse problems might feel very ashamed and therefore avoid talking about it. This is why it is very important that you look for the signs explained below when you are doing your assessment.
What is thought to cause substance misuse? Most people start using alcohol or illicit drugs because it makes them feel good. After a time they may start using alcohol or illicit drugs to help them deal with stress. Sometimes people use alcohol or illicit drugs because they have a mental illness and they want to feel better quickly.
Problems with substance misuse tend to run in the family. This means a person is more likely to have a problem with alcohol or illicit drugs if others in the family have had the same problem.
Assessing someone when you suspect substance misuse You should ask everyone that you see whether they use alcohol or illicit drugs. Pay extra attention to people who come to see you with the following problems: • Accidents and injuries that have strange explanations. • Burning pains in the stomach or vomiting blood. • A person having problems with their partner of friends. • Repeated sickness and absence from work. • Sleep difficulties. • Sexual difficulties. • Depression or anxiety.
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Questions to ask during your assessment The CAGE questions are very helpful. If a person answers yes to two of the following questions it means they are at risk of having substance misuse: C: Has anyone ever told you to Cut down your drinking? A: Has anyone ever made you Angry by telling you to drink less? G: Have you ever felt Guilty about your drinking? E: Have you ever had a drink in the morning to help open your Eyes and make you feel better?
If the person answers yes to two or more of the CAGE questions then you need to ask the following questions about dependency: • How much do you drink each day? Often a person may find this hard. Get them to tell you how much alcohol or illicit drugs they used yesterday, then the day before that, then the day before that and so on. A pattern should emerge about how much alcohol and illicit drugs they use. • Do they ever get a withdrawal reaction when they haven’t used alcohol or illicit drugs? For example getting anxious, sweaty or starting to shake when they have not used alcohol or illicit drugs? • Does the withdrawal reaction go away when they use alcohol or illicit drugs? • Do they have to use more and more alcohol or illicit drugs to feel good?
Safety questions to ask during your assessment • How much has the person been eating and drinking? People who use too much alcohol or illicit drugs often eat and drink too little. This puts their physical health at risk. • Has the person ever thought about hurting themselves or anyone else? What have they done? Often people will hurt themselves or others when they are drunk or high on illicit drugs. People are often likely to have put themselves at risk of getting diseases when they are drunk or high on illicit drugs.
For example, a person may have had unsafe sex with other people when drunk and so put themselves at risk of catching HIV. A person who shares needles when injecting illicit drugs is also at increased risk of catching hepatitis or HIV. It is important that you ask about these things.
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Things to look for during your assessment • Jaundice. This is when a person’s skin or eyes appear yellow in colour. This indicates that the person’s liver has been damaged by alcohol or illicit drugs. • Nervousness. If the person looks tense, nervous or they shake, it can be a sign that a person with alcohol or street drug dependency is having a withdrawal reaction. • Smell. If the person smells of alcohol. • Injury. Look for bruises or scars, they may have hurt themselves whilst they were drunk. Some people who inject illicit drugs have bruises on their arms or legs. • General appearance. Is the person is very thin, smelly or dirty? People who have a dependency spend all their money on alcohol or illicit drugs and do not look after themselves well.
Things to do during your assessment • Make sure you do tests for confusion. A person who is confused can be having a withdrawal reaction. • Make sure you do a physical health check. A person who is shaking or who has a high pulse (over 100 beats per minute) or a low blood pressure, may be having a withdrawal reaction. • People who have a substance misuse problem often deny anything is wrong. Always make sure you speak to a family member or someone else who knows what has been going on and ask them if the person has been using alcohol or illicit drugs.
What is the treatment for substance misuse? If a person is dependent they should always stop using alcohol or illicit drugs slowly. This is to avoid having a withdrawal reaction.
For example: If a person drinks 10 glasses of beer each day and wants to stop using alcohol: • On day 1 they should drink 9 glasses of beer. • On day 2 they should drink 8 glasses of beer. • On day 3 they should drink 7 glasses of beer, and so on until the person slowly stops drinking alcohol completely. This will allow the persons body to get used to not having alcohol and will avoid a withdrawal reaction.
This approach can be used for whatever the person is dependent on, whether it is illicit drugs, sleeping tablets or alcohol.
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Emergency treatment of an alcohol withdrawal reaction When a person has been drinking too much alcohol for a long time they can become very ill if they stop drinking alcohol suddenly. This normally occurs between four and 12 hours after they last had a drink and can continue for one week. This is a very serious illness, which can kill the person in some cases! At first the person will be: • Sweating • Shaking • Have an increased pulse (over 100 beats each minute) • Later on the person will become confused and have the features of delirium (this is covered in section 5.1 ) • After this the person can go on to have seizures (these are also covered in section 5.2 ).
If you think a person is having an alcohol withdrawal reaction they need to be sent to a health worker who can deal with the problem as soon as possible (see your crisis plan )
If you are able to prescribe medicines, you can do the following to treat an alcohol withdrawal reaction: Day one • Give thiamine 100mg by intramuscular injection. • Give 10mg diazepam tablet twice (at breakfast, and in the evening). Day two • Give thiamine 100mg by intramuscular injection. • Give 10mg diazepam tablet twice (at breakfast, and in the evening). Day three • Give thiamine 100mg by intramuscular injection. • Give 5mg of diazepam three times (at breakfast, afternoon and at bedtime). Day four • Give 5mg of diazepam three times (at breakfast, afternoon and at bedtime). • Give 50mg of thiamine tablet. Day five • Give 5mg of diazepam two times (at breakfast and at bedtime). • Give 50mg of thiamine tablet. Day six • Give 5mg of diazepam at bedtime. • Give 50mg of thiamine tablet. 60
Day seven • Give 2.5mg of diazepam at bedtime. • Give 50mg of thiamine tablet.
During this time the person can also be given an additional 10mg of diazepam for any symptoms they have such as agitation or tremor. The maximum dose of diazepam is 30mg in 24 hours.
The person should also be given 5mg of folic acid tablet and a multivitamin tablet to from day one to seven.
Make sure the person is drinking enough fluid and eating regularly
Long term treatment Each person needs to decide if they are going to stop alcohol or illicit drugs completely (this is called abstinence) or if they are going to try and not use as much as they did before (this is called harm reduction). It is best to encourage all the people you see to aim for abstinence from alcohol or illicit drugs.
Often people with substance misuse do not like being told what to do. It can be helpful to let the person work out for themselves what the risks are to their physical and mental health. A good way to do this is to get a piece of paper and ask the person to draw a line down the middle of it. If they can not write, you can do this for them. On the left-hand side of the piece of paper they should write all the good things about using alcohol or illicit drugs. A person will usually write a few things like “it makes me feel good”. On the other side of the piece of paper you should get them to write all the bad things about using alcohol or illicit drugs they can think of. Once they have run out of ideas you can ask them to write down even more bad things about using alcohol and illicit drugs from this list below: • Withdrawal reactions such as seizures (this can kill). • Memory problems or brain damage. • Stomach ulcers. • Pancreatitis (this can kill). • Problems with the liver such as hepatitis (this medical condition can kill a person). • Heart problems (this can kill a person). • Anaemia. • Problems sleeping. • Using too much alcohol or illicit drugs makes all physical illnesses worse. 61
• Alcohol and illicit drugs interact with medicine for physical illnesses. This means a person can have more side-effects, which can lead to drowsiness and accidents. • Alcohol and illicit drugs make a person more likely to have a mental illness. It can also make an existing mental illness worse. • Alcohol and illicit drugs can stop a person from being able to have good sexual relations. They can also stop a man from having erections! • It can be helpful to get a person to write down how much money they spend on alcohol or illicit drugs. They should then imagine all the other things they could spend this money on. Often the person will be very surprised at how much their substance misuse is costing them! • Often a person’s family and friends will get tired of them using alcohol or illicit drugs. People who use too much alcohol or illicit drugs often find themselves left on their own. • People who drink too much alcohol or use illicit drugs are very likely to get into trouble with the police at some point.
Once you have finished writing the list, ask the person what they think about it. The person should be able to see that there are many more bad things about using alcohol and illicit drugs than there are good things. The final step is to ask the person what they want to do about using alcohol or illicit drugs now they have a list of good and bad things. It can be helpful to say something like:
“What happens next is up to you. There seems to be a lot more negative, than good things about what you are doing. At the end of the day however it is your body, your mind and your life. We would very much like to help you but first of all the most important thing is that you decide what you want to do”.
The person will then usually make a decision about whether they want anymore help from you or not. Ask the person to keep the list with them at all times. They should look at it every time they are thinking about using alcohol or illicit drugs. If they can not read, ask them to try memorise the things on the list.
Long term treatment: Medicine (biological treatment) Medicine is not given in Ghana to help people to stop using alcohol or illicit drugs.
A person who has had a substance misuse problem is more likely to get addicted to other things. They should avoid taking medicines that are addictive and should speak to a doctor or pharmacist 62
before taking other medicines in the future. If a person has been dependent on sleeping pills in the past they should not take them again. They may go to other doctors to ask for more sleeping tablets. It is important that you notify other health professionals if a person is doing this.
People who have a substance misuse problem are more likely to get a physical and mental illnesses. If you think that a person with substance misuse has a physical or mental illness it is best to get them to stop using alcohol or illicit drugs first. Often the other mental illness will get better in a few weeks (this is explained in more detail in chapter 4). If they do not get better or they do not want to stop using alcohol or illicit drugs, ask the person to see a specialist before giving them medicine for mental illness (see your crisis plan). Giving medicine to someone who uses too much alcohol or illicit drugs can lead to dangerous side-effects.
If the person has any physical problems it is worth getting them to see a doctor for a physical health check. Sharing needles can spread HIV. If a person has shared needles or tools for injecting illicit drugs advise them to have an HIV test. If the person has had unsafe sex when they were drunk or high on illicit drugs you should advise them to go for an HIV test. Give advice on safe sex to anyone you see who has a substance misuse problem.
Long term treatment: Talking cures (psychological treatment) A type of counselling called group therapy can be very helpful for people trying to stay away from alcohol or illicit drugs. There is a world-wide organisation called Alcoholics Anonymous (AA) that helps people to stay away from alcohol. An organisation called Narcotics Anonymous (NA) helps people to stay away from illicit drugs. These organisations have meetings at all times in most places around the world. You can find out where the nearest group is at the following websites: • www.alcoholics-anonymous.org • www.na.org
These organisations will also be able to help your mental health team set up local meetings if there are not any in your area.
Problem solving work and relaxation techniques (section 3.2) can be useful in helping a person deal with stress so they don’t have to drink alcohol or use illicit drugs.
Coping strategies (section 3.2.5) are very useful in helping a person stay away from alcohol and illicit drugs. Get them to come up with a plan for what they will do next time they are tempted to use alcohol or illicit drugs. Possible things to put in the plan include:
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• Keeping themselves busy or going to places where they cannot use alcohol or illicit drugs (for example to Church or the Mosque). • Trying to avoid friends who drink alcohol or use illicit drugs.
A Crisis plan can also be worked out with the person and their family. This tells them what to do if the person starts using alcohol or illicit drugs again in the future (crisis plans are explained in section 3.2.4 ).
Long term treatment: Building the best life possible (social treatment) It is important to help a person build the best life possible after they have stopped using alcohol or illicit drugs.
They will often have very bad sleep for several months. You can help them get better sleep by using the advice on fact sheet 2 .
A person will often feel very bored once they have stopped using alcohol or illicit drugs. Using alcohol or illicit drugs may have been the only fun they had in their life for a very long time. It is important that you help the person find new, enjoyable things to do with their life that does not involve drinking alcohol or using illicit drugs.
What to do if a person still wants to use alcohol or illicit drugs Try to help build the best life possible for a person who wants to keep using alcohol or illicit drugs. This will help them to trust you and maybe in the future they will come back to see you again if they decide to stop. The following is helpful advice to give. • Agree to use as little alcohol or illicit drugs as possible. • Set a weekly limit and keep to it. For example a man who wants to keep drinking alcohol even though he knows it is bad for him might agree to drink no more than the safe amount of 21 drinks each week. • Do not drink alcohol or use illicit drugs alone. • Do not drink alcohol or illicit drugs with people you think might tempt you to use more than you normally use. • Make sure you have a non-alcoholic drink in between each alcoholic drink. • Don’t drink ‘straight’ alcohol; try to mix it with a little water (not soda) so one drink lasts longer. • Eat before you have your first drink or before you use illicit drugs. This will help keep your stomach healthy. 64
• Do not use alcohol to quench your thirst, have water instead. • Plan nice things to do that do not involve drinking alcohol or using illicit drugs. • Advise people who wish to keep injecting drugs not to share needles or tools for preparing illicit drugs. Sharing needles and tools can spread HIV.
A person cannot be admitted to hospital or kept in hospital if they choose to keep using alcohol or illicit drugs .
What next? Nobody should drink more alcohol than the safe amounts shown at the start of this chapter.
A person should never drink alcohol: • if they are driving • if they have to operate machines or tools • if the person is too young to legally drink • if they are pregnant or breast-feeding.
Most people with substance misuse will try and fail several times to give up alcohol or drugs before they succeed. Always encourage the person to keep trying. Having a job and a supportive family can help a person give up alcohol or illicit drugs.
Further reading The Royal College of Psychiatrists website provides downloadable information for carers, professionals and people with substance misuse problems: www.rcpsych.ac.uk/mentalhealthinformation.aspx 65
CHAPTER 7 Psychosis
People with psychosis find it difficult to understand what is real and what it not real. We often say that they have ‘lost contact with reality’.
What are the key features of psychosis? The key features of psychosis can be grouped into positive symptoms and negative symptoms.
The positive symptoms of psychosis • The person believes in strange things that you know are not true. For example, they may believe that they have an enemy who is trying to hurt them. These types of beliefs are called delusions . • The person believes that they can hear voices. The voices will sound like they are coming from outside the person’s head, for example the voices might sound like they are coming from the corner of the room. Sometimes a person with psychosis can believe they are being touched by someone who they (or you) can not see. These types of experiences are called hallucinations . Sometimes the voice a person hears may command them to do things. This is called a command hallucination .
Another type of hallucination is when a person actually sees something or someone who is not there. This is not likely to be caused by psychosis but more likely to be caused by an organic mental illness such as delirium (see section 5.1). • The person believes that someone or something is controlling their mind (thought interference) and /or their body (somatic passivity). • The person’s speech and thoughts may be muddled and make no sense (thought disorder).
The negative symptoms of psychosis Here it can seem as though the person has slowed down. They may say less, do less and take poor care of themselves. It is different from depression because in depression a person feels sad or cries (see section 8.1 ). The person with negative symptoms of psychosis is not sad, instead they may say that they feel nothing.
Who gets psychosis? Around 1 in every 100 people around the world get psychosis. The same numbers of men as women get psychosis. Most people will first get unwell with psychosis between the ages of 20 and 30. 66
What is thought to cause psychosis? If psychosis starts over a few days or weeks then it is known as acute psychosis . This can be caused by: Formatted: a physical illness Bullets and Numbering alcohol or illicit drug use certain medicines for physical illness.
If the psychosis develops over a few months and has none of the above causes then it is known as schizophrenia.
Questions to ask during your assessment • Does the person feel frightened for any reason? If they do, why? • Have they had any strange experiences that other people don’t notice? For example, have they heard noises or voices when no one is there? Make sure the person is not experiencing these strange things only when they are asleep. People often say they ‘see’ or ‘hear’ strange things which are in fact only dreams. Dreams are completely normal and do not need treatment. • Has the person been drinking alcohol or using illicit drugs? • Is the person taking any medicine for a physical illness? • Have they thought about hurting themselves or anyone else? Section 2.3 suggests ways in which you can ask this difficult question. If a person ever tells you they have been feeling so angry or frightened they want to kill themselves or someone else, then speak to a senior colleague about what to do next. • Ask about any recent physical illness (see section 2.3 ), particularly if the psychosis has suddenly become worse.
Things to look for during your assessment • The person with psychosis may not be well dressed. They may be dirty and smelly because they have been too frightened to look after themselves. • The person will often stare at you in a very intense way if they have the positive sy mptoms of psychosis. • The person may look very blank if they have the negative symptoms of psychosis. • The person may look very frightened or suspicious. • The person may look around the room at things that are not there if they are experiencing an hallucination. • The person’s speech or actions may make little sense or seem disorganised. 67
Things to do during your assessment • Make sure you do tests for confusion (see section 2.4 ). A person with psychosis will usually not be confused. A person with delirium will always be confused (see section 5.1 ). • Make sure you do a physical health check. • Make sure you get the whole story. Ask a close friend or relative if they have been using alcohol or illicit drugs or if they are taking medicine for a physical illness. Ask how long the strange behaviour has been going on for. This is important as delirium will start suddenly over a few days with evidence of physical illness or substance misuse whereas psychosis will begin gradually over weeks to months.
Treatment: Medicine (biological treatment) Nearly everybody with psychosis will need to take medicine to get better. However before you start any medicine: • Make sure the psychosis is not due to a physical illness. If you think the person has a physical illness that may be causing the psychosis this needs to be treated immediately (before the mental illness) . The person should be taken to a health worker who is qualified to deal with physical illness. Appendix 2 gives more information on managing physical illness. • If the person is taking other medicines for a physical illness, speak with a doctor or pharmacist before starting any new medicine for the psychosis. Make sure the medicine for the physical illness is not making the psychosis worse. If you have a copy of the BNF (British National Formulary) you can check the side-effects of most medicines to see if they cause psychosis.
The best medicines for psychosis are anti-psychotics . The most common types of anti- psychotics are olanzapine, chlorpromazine, haloperidol, and trifluoperazine (see appendix 1). If available the first medicine you should try giving a person with psychosis is olanzepine (also known as zyprexa). If a person has been successfully treated with chlorpromazine, haloperidol or trifluoperazine and has no unpleasant side-effects from the medicine there is no need to change them to olanzepine.
If a person has been unwell with psychosis many times before and does not reliably take medicine, they may need to be given regular injections of medicine by a health worker to keep them well. A person who takes tablet medicine should not be given injections at the same time. Anti-psychotic injections used include fluphenazine decanoate (also known as modecate) which is injected into the gluteal (buttock) muscle. This is a powerful drug and should be administered appropriately. For information on how to administer fluphenazine decanoate, see appendix 1 . 68
People who have been given anti-psychotic medicines are likely to experience side-effects such as acute dystonic reactions, akathisia and anti-psychotic induced Parkinsonism (see chapter 15 ).
Remember to follow the advice for side-effects given in chapter 3; if a person is having side-effects first reduce the dose of medication. If this does not work change the medicine to another that has less side-effects (in this case change chlorpromazine or haloperidol to olanzepine). If a person still has side-effects after reducing the dose of medicine or changing to olanzepine, they may need to take a remedy for the side-effects (see chapter 15 for more details). Remember to review the need for these remedy medicines regularly.
If a person has ever tried to kill themselves, you should get another person to ensure the person with psychosis is taking their medicine. This will stop the person with psychosis from taking too many tablets and hurting themselves. Tell the person who is looking after the medicine how to give it correctly.
Treatment: Talking cures (psychological treatment) The talking cures explained in section 3.2 can benefit a person with psychosis. Normally a person needs to be on medicine for several weeks before talking cures can be tried. Once a person starts to get better it is important that talking cures are used as well as medicine.
Coping strategies (see section 3.2.5 ) can be extremely helpful in reducing the distress a person with psychosis experiences. Listening to music or the radio (particularly through headphones) can stop a person from hearing hallucinations or voices that are saying bad things about them. If a person feels frightened or paranoid because of delusions, you can help them find ways to take their mind off these worries.
Teaching a person to deal with stress can be very helpful in stopping psychosis from happening again (see section 3.2 for ways to help a person deal with stress).
Treatment: Building the best life possible (social treatment) A person with psychosis can also benefit from social treatment as outlined in section 3.3 . Normally a person needs to be on medicine for several weeks before you can help them with social treatment. Once a person starts to get better it is important that social treatments are used as well as medicine.
The relationship between the person and their family is very important in psychosis. Managing expressed emotion has been proven to stop psychosis from happening again (see section 3.3.2 for how to do this). 69
It is also very useful to work out a relapse prevention plan with the person and their family. This can stop psychosis from happening again. (See section 3.3.3 ).
What next? One in every three people with schizophrenia never has it again. The other two in every three people will.
There is no way to tell who will have psychosis again and who will not. To try and stop psychosis from happening again a person needs to stay on their medicine for at least two years after they get better and follow the other treatments explained above. If they stay well for this time then they need to see a specialist for advice about stopping the medicine slowly over several months.
Further reading The Royal College of Psychiatrists website provides downloadable information for carers, professionals and people with psychosis: www.rcpsych.ac.uk/mentalhealthinformation.aspx
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CHAPTER 8 Mood disorders
8.1 Depression Depression is often thought of as a person feeling bad or sad. Anybody can feel sad after bad things have happened to them. However a person with depression stays feeling bad for far longer than would be normal. The person feeling bad causes difficulties to both themselves and to others around them.
What are the key features of depression? For a person to be depressed they must have experienced the following for at least two weeks: • They may feel sad or down. • They may have lost interest in their normal daily activities. • They may feel tense and find themselves worrying a lot.
People with depression can also suffer from the following: • Poor sleep • Waking up too early in the morning • Feeling tired all of the time • A loss of appetite • A loss of weight • Tearfulness • Poor concentration • Thoughts of suicide • Feeling guilty • A loss of interest in sex • A person may feel worse in the mornings • Aches and pains all over the body • Feeling the heart beating in the chest (palpitations).
Sometimes the depression can be so bad that the person loses contact with reality. This is depression with psychotic features . Here the person will have strange beliefs and experiences, as is the case with psychosis (see chapter 7). However in depression with psychotic features the person’s strange beliefs and experiences will normally involve sad, depressed things. For example they may feel: • They have lost things such as all of their money or possessions. 71
• They may feel that nobody likes them and that their friends or family are talking about them behind their back. • The person may believe they have no stomach and therefore cannot eat food. • The person may become religious in a way that others of the same faith cannot understand. An example of this would be someone who decides they must fast continuously, when others of the same religion would not normally do this. • They may hear voices; if this is the case the voices will say bad things about them. For example, a voice may say that they are worthless.
In depression with psychotic features the person will usually feel sad or bad for a few weeks before starting to have strange experiences. In psychosis the person usually has strange experiences first.
Who gets depression? Depression is more common in women than men, in fact twice as many women get depression as men.
Depression usually starts between the ages of 30 to 45 years. Depression is very common around the world. Some research has shown that one in every five people will suffer from depression at some point in their lives.
What is thought to cause depression? As with most mental illness the cause for depression is unknown in most cases. As we discussed in chapter 1, a number of events can lead to a chemical imbalance in the brain that can lead to mental illness including depression.
However, the following things are thought to be of particular importance in a person developing depression: • A stressful event such as a close friend or relative dying. • A lack of people around to support when help is needed. • The use of alcohol or illicit drugs.
In some cases a physical illness can cause depression or make depression worse. These physical illnesses include: • Problems with the thyroid gland or other hormonal problems. • Low levels of certain vitamins such as vitamin B. • Infections, such as HIV. 72
• Side-effects from some medicines for physical illness, for example, chloroquine and mefloquine (malaria treatment). Other important examples include medicines for the heart (beta-blockers like atenolol, diuretics and digoxin) as well as steroids.
Assessing someone when you suspect depression Always consider depression if a person comes to see you with the following problems: • Difficulty sleeping • Feeling tired all of the time • Relationship problems • Sexual problems.
Questions to ask during your assessment • Ask the person if they are feeling sad or bad about anything. • Find out if there is anything that they normally enjoy doing but have stopped doing? For example, a person may have stopped playing with their children, seeing their friends or going to work. • Ask if the person has been having trouble concentrating. For example a person may say they used to watch a whole movie on television, but now they only watch television for a few minutes at a time. A religious person who has difficulties concentrating may also have difficulties praying. • Ask about how much they are eating and drinking. Ask a person how many meals they used to eat each day, and ask how many meals they eat now. Ask the person if they still enjoy eating food. A person who is depressed may stop enjoying eating. • Find out if they have lost any weight. If a person does not know how much they weigh you could ask them if their clothes have been feeling looser than usual or if they have had to make their belt tighter. • Make sure you ask if the person has thought about hurting themselves or anyone else. Section 2.3 explains how this question can be approached. If a person ever tells you they have been feeling so bad they want to kill themselves, speak to a senior colleague about what to do next (see your crisis plan ).
Things to look for during your assessment • A person with depression often does not look after themselves. You may notice that they are not dressed properly. They may be smelly and have dirty clothes. • They may have lost weight and appear thin. 73
• The person’s face will usually look sad. They may also have no expression on their face. • The person may not react normally to the things you say. For example it may take them a long time to answer your questions. Or they may not smile when you talk about something happy. • The person’s voice may be quiet. They may say things slowly. They may speak in a way that is flat or very monotonous.
Things to do during your assessment • Make sure you do a physical health check . If you think the person has a physical illness that may be causing the depression, get them to see a health worker who can deal with this. The physical illness will need to be treated before the depression can get better. The person should be taken to a health worker who is qualified to deal with physical illness. Appendix 2 gives more information on managing physical illness. • Make sure you speak to someone else who knows what has been going on. Often people who have depression will not tell you how bad things have been. For example they may have tried to kill themselves but they are now too embarrassed to tell you about it.
Treatment: Medicine (biological treatment) Sometimes a person with depression may not need to be treated with medicine. If the person has lots of people around who can help to support them, it may be possible to use talking cures (psychological treatment) or to help them build the best life possible (social treatment).
Depression should be treated with medicine if: • A person feels so bad they are thinking about hurting themselves or somebody else. • A person does not get better after a few weeks of talking cures (psychological treatment) and efforts to help them to build a better life (social treatment). • A person has nobody around to help and support them.
If a person has ever tried to kill themselves in the past you should get another person to look after their medicine. This will stop the person with depression from taking too many tablets and hurting themselves.
If you think a person may have depression with psychotic features, speak to a senior health worker about what to do next. A person with depression with psychotic features may have to be on two medicines. It is best to let a specialist decide what to do if this is the case.
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Amitriptyline, imipramine, sertraline and fluoxetine are good medicines to treat depression. If available use sertraline (also known as lustral) or fluoxetine (prozac), this is because these medicines have few side effects. Appendix 1 provides information on all of these medicines, how to take them and how to manage the side-effects.
Treatment: Talking cures (psychological treatment) All of the talking cures explained in section 3.2 can make depression better. If a person is taking medicine to treat their depression, it is important that talking cures are used at the same time.
When a person starts getting better from depression they can actually be at more risk of hurting themselves. This is because they now have the energy to kill themselves. This is why it is a good idea to do a crisis plan with a person and their family so they know what to do if the person suddenly feels like killing themselves. (See section 3.3.3 and fact sheet 1 for more information on crisis plans).
Treatment: Building the best life possible (social treatment) Section 3.3 explains how social treatment can be used to treat mental illness. This type of treatment is very helpful for people with depression.
What next? In most cases the depression lasts between 3 and 6 months. One in every three people who have had depression will get it again in the next 10 years. To prevent this from happening, everyone who has had depression should stay on medicine (if given) for at least six months after getting better . After this time they should see a health worker to speak about slowly stopping the medicine over another three months.
If the person has been unwell with depression before and this is the second time they have been unwell. Then the person should stay on medicine (if given) for at least two years after getting better.
Further reading The Royal College of Psychiatrists website provides downloadable information for carers, professionals and people with depression: www.rcpsych.ac.uk/mentalhealthinformation.aspx
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8.2 Mania and manic depression (bipolar mood disorder) Mania is often thought of as a person feeling too good. Anybody can feel good after good things have happened to them. However a person with mania stays feeling good for far longer than normal. The person feeling good causes problems to themselves and to others around them.
A person with manic depression will fluctuate between feeling normal, feeling manic and feeling depressed. For the illness to be classed as manic depression, the periods of mania or depression should last between one week and many months. The person should also have at least two manic episodes or an episode of mania followed by an episode of depression before they are said to have manic depression. It is thought that everyone who has a first episode of mania will over time go on to develop manic depression.
Another term for manic depression is bipolar mood disorder .
What are the key features of mania and manic depression? • The person with mania feels better than a normal person does in the same situation. They may say they feel the best they have ever felt! • The person can also feel angry for no obvious reason. • They may be more interested in sex than usual. They may speak about sex in an inappropriate way. • They may have a large amount of energy and try to do too many things. • Their behaviour may be excited, agitated or aggressi ve for no obvious reason. • They may have an increased appetite. • They may need to sleep less than usual. • They may ‘think’ too much. People may say the person has ‘too many thoughts’ (this is called ‘flight of ideas’). • The person may speak too quickly for other people to understand what they are saying (this is called ‘pressure of speech’). • They may show poor judgement. For example, they may spend all of their money on inappropriate things. • They may take their clothes off in public. • They may feel like they are special. For example, a person with mania may think that they are the King of the world! • They may believe they have special powers. For example, they might think that they can speak to people who are far away – without using a telephone.
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When a person with manic depression gets depressed (as opposed to manic) they have the same features of depression as explained earlier in this chapter.
Who gets mania or manic depression? About one in every 100 people will get manic depression. The same number of men and women get manic depression. Most people who have manic depression will become unwell between the ages of 20 to 30 years.
What is thought to cause mania or manic depression? The cause for mania and manic depression is unknown in most cases. As we discussed in chapter 1, a number of events can lead to a chemical imbalance in the brain that can lead to mental illness including mania and manic depression.
However, the following things are thought to be important factors in a person developing manic depression: • Having someone else in the family who has mania or manic depression. • A stressful event such as a close friend or relative dying. • The use of alcohol or illicit drugs. • Mania or manic depression can be caused by physical illness, for example: • Epilepsy • Infections (HIV) • Head injury • An overactive thyroid gland
There are also some medicines that can cause a person to have mania. These include: • Medicine for TB • Anti-depressants • Steroids • Painkillers
Questions to ask during your assessment • Is the person feeling very good or very angry for no reason? • How many hours a night does the person sleep? A person with mania will need to sleep less than they normally do. • Has the person been drinking alcohol or using illicit drugs? • Is the person on any medicine for a physical illness? 77
• Make sure you ask if the person has thought about hurting themselves or somebody else. Section 2.3 provides some helpful advice on how to ask this difficult question. If a person ever tells you they have been feeling so upset they want to kill themselves or someone else, then speak to a senior colleague about what to do next (see your crisis plan). • Ask about recent physical illnesses (see section 2.3 ), particularly if the mania has developed quickly or has suddenly got worse.
Things to look for during your assessment • The person with mania may be wearing strange clothes. Or they may remove their clothes inappropriately. People with mania may also wear sunglasses indoors because they find normal light too bright. • Their face will often stare at you in a very intense way. • Their voice may be very loud. • They may speak too quickly. • They may not allow you to interrupt them. • They may make no sense and they may change the subject they are talking about very quickly (this is called distractibility).
Things to do during your assessment • Make sure you do a physical health check (see section 2.5 ). • Make sure you speak to someone else who knows what has been going on. Ask them if they know whether the person with mania has been using alcohol or illicit drugs or if they are taking medicine for a physical illness.
Treatment: Medicine (biological treatment) Nearly everybody with mania or manic depression will need to take medicine to get better. However before you start any medicine, check the following: • The mania is not caused by a physical illness. If you think it is, then the physical illness needs to be treated immediately (before the mental illness). The person should be taken to a health worker who is qualified to deal with physical illness. Appendix 2 provides more information on managing physical illness. If possible, people with mania should have blood tests including thyroid function tests (TFTs). • If the person is taking other medicines for a physical illness, speak with a doctor or pharmacist before starting any new medicine for the mania. Make sure the medicine for the physical illness is not making the mania worse. If you have a copy of the BNF (British National Formulary) you can look up each medicine to see if mania is listed as a side- 78
effect. If you find out that they are taking medicines that cause mania – stop the medicine and start a different medicine. If you have any doubts speak to a doctor or pharmacist.
The next stage in treating mania is to stop any anti-depressant medicine as these will make the mania worse.
Medicines used to treat bipolar mood disorder include olanzapine, sodium valproate and carbamazepine.
The best medicine to use to treat manic depression is olanzapine (also known as zyprexa). The next best choice is sodium valproate (epilim) followed by carbamazepine (also known as tegretol). Often a person with mania may be extremely agitated. If they do not calm down after being treated with olanzapine, sodium valproate or carbamazepine they can be given a sedative medicine such as lorazepam or diazepam. These sedative medicines should be gradually stopped once the person’s behaviour has become calm. See chapter 16 for the management of violence and aggression.
If a person with bipolar mood disorder does not get better, check chapter 3 for the list of things that may prevent people with mental illness from getting better. If they still do not improve, it is possible to combine two types of medicine to treat bipolar mood disorder. The safest combination of medicines to give is olanzapine and sodium valproate. For information on how to administer these medicines appropriately, see appendix 1.
People who have had manic depression should not be treated with anti-depressant medicines as this can make them unwell again. If a person with bipolar mood disorder is depressed, the dose of the medicine they are taking (olanzepine, sodium valproate or carbamzepine) should be increased. They should also be treated with talking cures whenever possible.
In some parts of the world people with manic depression are treated with lithium. You may encounter this medicine. See section 15.7 for more information on the serious problems lithium can cause.
If a person has ever tried to kill themselves, you should get another person to look after their medicine. This will stop the person from taking too many tablets and hurting themselves.
Treatment: Talking cures (psychological treatment) 79
The talking cures explained in section 3.2 can benefit someone with mania or manic depression. Normally a person needs to be on medicine for several weeks before talking cures can be tried. Once a person starts to improve it is important that talking cures are used as well as medicine. Teaching a person to deal with stress can also be very helpful in stopping mania or manic depression from happening again (see section 3.2 ).
Treatment: Building the best life possible (social treatment) Helping a person to build a better life can be used to make someone with mania or manic depression better. Normally a person needs to be on medicine for several weeks before you can help them with social treatment. Once a person starts to get better it is important that social treatments are used as well as medicine. A daily routine that includes regular sleep, food, rest and exercise helps people with bipolar mood disorder stay well. It is very helpful to teach people with manic depression ‘sleep hygiene’ in order for them to get the best sleep possible (see fact sheet 2 ).
It is also useful to work out a relapse prevention plan with the person and their family. This can stop mania or manic depression happening again (see section 3.3.3 for more information on relapse prevention plans).
What next? In most cases a person who develops mania or an episode of manic depression will get better within a few months. About half of the people who have mania will get unwell again within the next two years. In order to stop this from happening it is important that the person stays on medicine for as long as possible. A person who has had mania or manic depression should stay on their medicine for at least two years after getting better. If they get better after this time, they should see a specialist doctor about stopping the medicine very slowly (for example over at least 3 months).
The medicines used to treat mania or manic depression are very powerful. It is very important that women taking these medicines do not get pregnant or breast-feed whilst taking the medicine. Tell women taking medicine for mania or manic depression that they can get pregnant, however they need to see a specialist doctor for advice first (see chapter 10 for more information).
Further reading The Royal College of Psychiatrists website provides downloadable information for carers, professionals and people with mania and manic depression: www.rcpsych.ac.uk/mentalhealthinformation.aspx 80
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CHAPTER 9 Anxiety disorders
9.1 Panic attacks, phobias and generalised anxiety disorders
When a person worries a lot or feels afraid it is called anxiety.
What are the key features of anxiety? A person with anxiety may feel: Formatted: like their heart is beating too quickly Bullets and Numbering (palpitations) pains in their chest shaky short of breath as if they are choking dizzy like they are going to vomit (nausea) like they have lost control of their mind or are going crazy like they are going to die.
If the anxiety happens very quickly and lasts for about 10 minutes it is called a panic attack . In most cases panic attacks happen for no reason. If the features of a panic attack reoccur each time a person is exposed to a particular situation or object, then they are said to be experiencing a phobia . When panic attacks make a person stay away from crowded places or stops them from travelling away from their home, then they are said to be experiencing agoraphobia . Sometimes a person will feel tense or afraid all of the time no matter what situation they are in. They will have some of the features of a panic attack but these will not be very severe. For example, the person may be afraid, but they do not feel as though they are going to die. This is called generalised anxiety disorder .
Who gets it? About eight in every 100 people will have a panic attack at some point in their life. Women are two to three times more likely to have panic attacks than men. Panic attacks usually start between the ages of 15–24 years or 45–54 years.
About 11 in every 100 people will experience a phobia in their life. Phobias tend to be more common in men. Phobias most often start around the age of 15. 82
About four in every 100 people will experience agoraphobia. Three times as many women experience agoraphobia as men. Agoraphobia most often starts between the ages of 15 to 35.
About three in every 100 people get generalised anxiety disorder. More women than men have generalised anxiety disorder. Generalised anxiety disorder can start at any time in life.
What is thought to cause these illnesses? As mentioned in chapter 1, many mental illnesses, including anxiety disorders, are caused by a chemical imbalance in the brain. Usually a series of events or situations cause the chemical imbalance in the first place.
With phobias and agoraphobia, a person is thought to ‘learn’ that it is normal to be afraid of a particular situation. The person will then learn to avoid this situation.
Heart problems or hormone imbalances such as hyperthyroidism can cause anxiety, however this is very rare.
Questions to ask during your assessment If you suspect an anxiety disorder, ask: • How often does the person feel afraid? • Has the person been avoiding any situations because of their fear? • Has the person been using alcohol, illicit drugs or sleeping tablets? Often people with anxiety use these substances in order to feel better. • Ask if the person is sad or has lost interest in their daily life. This is to make sure the person does not also have depression.
Things to look for during your assessment • The person with anxiety may have a tense or fearful look on their face. However, a person who is depressed will have a sad look on their face. • The person may be restless. They may bite their nails or move around in their chair.
Things to do during your assessment Do a physical health check to make sure that the person does not have a physical illness that could be causing the anxiety. If the person has panic attacks and it is the first time they have been seen by a health worker, then it is a good idea to speak to a senior colleague about 83
arranging some tests to make sure there is not a physical illness that is causing the panic attacks or making them worse. These physical tests will usually involve the blood tests discussed in chapter 2 . If possible, it is also a good idea to arrange a heart trace (ECG) for people who have panic attacks. In very rare cases a problem with the heart can cause panic attacks.
Treatment: Medicine (biological treatment) In most cases medicine should not be used for panic attacks, phobias or generalised anxiety disorder. It is best to try and use talking cures for these types of mental illness. However, if you have tried talking cures and they have not worked, there are two types of medicine that can be used: anti-depressants and anti-anxiety medicines.
Antidepressants should be used when: • The sy mptoms last for more than four weeks despite trying talking cures. • The person also has depression. • There are repeated panic attacks.
The best anti-depressant to use is sertraline or fluoxetine. Other anti-depressants that can be used include amitriptyline and imipramine.
Anti-anxiety medicine should be used when: • The person is so afraid, they cannot listen to your advice. • The person is very tense after a bad event. For example a husband or wife may have died. • The person has been so afraid they have not slept for several days.
Diazepam (valium), lorazepam and propranolol are anti-anxiety medicines that can be used. See appendix 1 for information on how to administer these medicines. Diazepam and lorazepam should never be used for more than two weeks to treat anxiety as people can easily become dependent on these medicines (see chapter 6).
Treatment: Talking cures (psychological treatment)
Dealing with general anxiety Often being diagnosed with a mental illness will make someone who is worrying, worry more. This creates a circle where the person worries about their diagnosis, their illness gets worse and so they worry even more! The only way for the person to feel better is for them to understand that their mental illness is the result of worrying . They then need to find ways to stop themselves from worrying too much. 84
You should teach relaxation exercises to people who worry (these are explained in section 3.2.3 and fact sheet 3 ). Relaxation exercises can help all people with anxiety disorders to control their worrying. You should also teach people who worry how to deal with stress. Problem solving can be very helpful. This is also explained in section 3.2.2. If a person knows how to deal with the problems in their life, they are less likely to worry.
Dealing with panic attacks If a person feels like they are about to have a panic attack, they should: • Remind themselves that they are breathing too quickly and to try and take control of their breathing. • Breathe in a slow, steady way by counting to three slowly whilst breathing in, and then counting to three slowly whilst breathing out. The person should continue breathing in this way until the panic attack stops. • Remind themselves what caused the panic attack (worrying and breathing too quickly). They should also remind themselves that nothing dangerous will happen to them and that nearly all panic attacks stop after about 30 minutes.
Dealing with a phobia or agoraphobia A phobia develops when a person learns to become afraid of an object, situation or place. They then learn to avoid the object, situation or place because of the fear. If a person’s phobia is making them unhappy they should be advised to: • Beat the fear by gradually placing themselves in the situation. The more they do this the more they will learn that they have nothing to be afraid of. If they keep avoiding the situation then the fear will get worse. • Learn the relaxation exercises described in section 3.2.3 and fact sheet 3 . • Make a list of situations that make them afraid. They should order these situations into those that make them least afraid through to situations that make them most afraid. They should then start by putting themselves in the situation that they find least frightening. When they are in the situation they should do relaxation exercises to help them feel calm. After doing this several times, the person should stop feeling afraid. They can then move to the next frightening situation. Here is an example:
Sherifa is a 27 year old lady who gets frightened when she leaves her house. With her mental health worker Sherifa listed the situations that made her afraid: 1. She found going into her yard the least frightening situation. 2. She found walking to the end of the street the next most frightening situation. 85
3. She found riding a tro tro the next most frightening situation. 4. She found going to the marketplace the most frightening situation.
The mental health worker showed Sherifa how to do relaxation exercises. She used the exercises in the following way: 1. She stood in her yard and did relaxation exercises. After doing this for 10 minutes she no longer felt afraid. 2. After this she walked to the end of the street and did relaxation exercises. After doing this every day for three days she no longer felt afraid. 3. After this she went on a tro tro and did relaxation exercises. After one week of doing this she no longer felt afraid going on tro tros. 4. After this she went to the market place and did her relaxation exercises. After doing this every day for four days she no longer felt frightened.
Treatment: Building the best life possible (social treatment) Section 3.3 explains how you can help someone to build a better life. These techniques are helpful to people who have panic attacks, phobia and generalised anxiety. Often people with these types of mental illness will need help to get good sleep. Advice to help a person have good sleep is given in fact sheet 2 .
What next? Without proper treatment, these types of mental illness can last for many years. With proper treatment people can do well and live a happy life. Most people with these illnesses will still have one or two of the features of anxiety even after treatment. It is therefore important that the person keeps practising their relaxation exercises. It is also important that the person avoids drinking alcohol as much as possible as this can make anxiety worse.
Further reading The Royal College of Psychiatrists website provides downloadable information for carers, professionals and people with anxiety related problems: www.rcpsych.ac.uk/mentalhealthinformation.aspx
9.2 Obsessive compulsive disorder (OCD) This is when a person can not stop thinking or doing things that they find silly or upsetting. It is also known as OCD.
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What are the key features of OCD? The person with OCD will: • Think things all the time that they find silly or upsetting. For example; a person may worry that they have not locked the door of their house. This may stop them from leaving the house and going to work. These silly or upsetting thoughts are called obsessions . • Doing things they find silly or upsetting. For example; a person may keep going back to check that the door of their house is locked even though they know they have done this many times already. These actions are called compulsions . • If the person tries to stop thinking or doing the silly or upsetting things they have the features of anxiety (see section 9.1 ).
OCD is not the same as psychosis. In psychosis the person does not know that the things they are thinking or doing are strange. In OCD the person does know that the things they are thinking or doing are strange (psychosis is explained in chapter 7 ).
Everybody can think or do things that are silly or upsetting from time to time. As explained in chapter 1, a person can only be said to be suffering OCD when the things they are doing or thinking cause a problem in their life or the lives of those around them. For example; a person with OCD may keep going back to check that the door of their house is locked all day even though they know this is silly. This means the person does not go to work. This causes a problem to both the person and their employer.
Who gets OCD? Around two in every 100 people will get OCD. Equal numbers of men and women get OCD. In most cases OCD starts between the ages of 20 to 25 years.
What is thought to cause OCD? In most cases OCD is thought to be due to a chemical imbalance in the brain. Due to this chemical imbalance, the brain learns to keep doing things that are silly or upsetting.
Questions to ask during your assessment Often a person with OCD is also suffering from depression. Make sure you ask the questions for depression covered in section 8.1 .
Ask the person what they think might be causing their problems. This will help you tell if the person has OCD or psychosis. The person with OCD will know that their worries are silly. They may say “it is all in my mind”. A person with psychosis will believe strongly that the strange things they are worrying about are true. 87
Often people with OCD drink too much alcohol or use illicit drugs – so make sure you ask about this.
Things to look for and to do during your assessment Make sure you speak to someone else who knows what has been going on. This will help you to decide if the person has OCD or psychosis. Other people will understand the worries that a person with OCD has (because everyone will have had worries like these from time to time). If a person has psychosis then others who know that person will not be able to understand the strange things the person is worrying about.
Treatment: Medicine (biological treatment) In some cases of OCD a person will not need to take medicine. It is therefore best to try talking cures first. If talking cures have not worked, certain types of anti-depressant medicines can be used.
Antidepressants should be used if: • The person also has depression. • The person does not get any better despite trying talking cures for at least four weeks. • The best medicine for OCD is fluoxetine or sertraline . See appendix 1 for instructions on how to use these medicines safely.
Treatment: Talking cures (psychological treatment) It is important to teach the person relaxation exercises for dealing with stress (explained in chapter 3 ). This will help the person with the next part of the treatment; exposure and response prevention.
Exposure and response prevention Here the person puts themselves in the situation where they normally experience obsessions or compulsions. By gradually dealing with the situation the person learns that they are in control and the illness is not!
Here is an example Abdul is a 21 year old man who has obsessions that his hands are covered in dirt. This makes him very anxious. To deal with this anxiety Abdul washes his hands many times each day. Abdul knows that his hands are really clean but he can’t stop doing it. Abdul’s hand washing is a compulsion.
A mental health worker advised him to do the following things: 88
To put his hands in a place where he worries about dirt e.g. on top of the rubbish bin. Formatted: Bullets and Numbering Once he has done this Abdul has to keep his hand on the top of the bin for a set period of time. For example, two minutes. This will probably make Abdul very anxious, in which case he should do the relaxation exercises explained in section 3.2.3. Abdul should try to keep his hand on the bin for two minutes until he has achieved his goal. Every day the length of time that Abdul keeps his hand on the bin should get longer and longer. Eventually he will be able to keep his hand on the bin for such a long time that he will no longer feel anxious.
If the person has only obsessions and not compulsions then the following technique can be useful: The person should write down all the silly and upsetting thoughts they have been having. If Formatted: Bullets and Numbering the person cannot read or write you should do this for them and ask them to memorise the list. Next the person writes down an alternative pleasant thought or situation for each silly or upsetting thing that they have been thinking. The person then starts practicing making themselves think the silly or upsetting thing. As soon as this happens they then imagine the word “STOP!” After this they will make themselves think about the pleasant thought or situation instead of the obsession.
These steps often sound strange and not like a ‘proper’ cure for mental illness like medicine. However research has shown that if these steps are followed many times, then the brain learns to stop thinking silly or upsetting things. Like physical exercise for the body, these techniques get more powerful the more they are practiced. Therefore, explain to the people you help that practice makes perfect!
Treatment: Building the best life possible (social treatment) Section 3.3 explains how ‘building the best life possible’ can help people with mental illness. These techniques can benefit people with OCD.
What next? More than half of all people with OCD do well with the proper treatment. A lot of people will still have some silly or upsetting thoughts from time to time, even after treatment. People with OCD can also get unwell when they stop treatment. It is therefore important that the person keeps following their treatment plan for as long as possible. 89
Further reading The Royal College of Psychiatrists website provides downloadable information for carers and people with OCD: www.rcpsych.ac.uk/mentalhealthinformation.aspx
9.3 Acute stress reactions
When a person becomes unwell after a very bad event, it is called an acute stress reaction. The bad event is likely to make any other person feel stressed in the same situation, but someone who has an acute stress reaction will have an extreme or amplified reaction to the event.
What are the key features of an acute stress reaction? An acute stress reaction will last for less than four weeks. During that time the person may have any of the following experiences: • Any of the features of depression ( section 8.1 ). • Any of the features of anxiety (this is explained earlier in this chapter). • The person may feel very angry. • The person may feel like they have no hope or future. This is called despair . • The person may be confused.
An acute stress reaction starts very suddenly (within a few hours) after a bad event. It will then stop very suddenly, for example, within a few hours or a few days. If an acute stress reaction continues for more than four weeks, it may have become a more serious mental illness such as post traumatic stress disorder, which is explained in section 9.4 .
Who gets an acute stress reaction? One in 5 people who experience a very bad event (for example a car crash) will have an acute stress reaction.
What is thought to cause an acute stress reaction? Acute stress reactions are an extreme response to stress.
Things to do during your assessment Doing the following will ensure you do not confuse an acute stress reaction with depression, anxiety or delirium. • Make sure you speak to someone else who knows what has been going on. An acute stress reaction starts very quickly after a bad event. Depression or anxiety will develop 90
more slowly over at least two weeks. A person with delirium will become confused quickly, but this will be unrelated to a stressful event. • Make sure you ask about any recent physical illness (see section 2.3 ). A person with delirium will have evidence of a recent physical illness, someone with an acute stress reaction will not. • Ask about the use of alcohol or illicit drugs. This is more common in people with delirium. • Make sure you test for confusion ( section 2.4 ).
Treatment: Medicine (biological treatment) In most cases medicine should not be used for acute stress reactions.
Treatment: Talking cures (psychological treatment) The best treatment for an acute stress reaction is to use talking cures such as counselling and relaxation exercises. See chapter 3 for more information on this.
What next? It is important to tell the person and their family not to worry. Once the stressful event has stopped, the person will usually get better within three days. If the person does not get better after three days, you could do another assessment or speak to another health worker for advice to make sure you have not made a mistake.
9.4 Post traumatic stress disorder (PTSD) Post traumatic stress disorder occurs when a very bad event has happened to a person. Usually this event will be so serious that the person’s life has been placed in danger and they have nearly died. It is different from a stress reaction because the illness lasts for longer than four weeks. Post traumatic stress disorder is also known as PTSD.
What are the key features of PSTD? Within six months of a very bad event the person with PSTD will experience some of the following things: • Problems sleeping. • Becoming angry very quickly. • Having problems concentrating. • Being on the look-out for danger all of the time. • Being surprised very easily. • Remembering the bad event as if it is happening again – this is known as a flashback . • Avoiding situations that may remind them of the bad event. 91
• Being unable to remember everything that happened during the bad event.
Who gets PTSD? About eight in every 100 people who have experienced a very bad event will get PSTD. Women are more likely to get PTSD than men. Women most commonly get PTSD after being raped. Men most commonly get PTSD after being in a war.
What is thought to cause PTSD? As mentioned in chapter 1, many mental illnesses, including PSTD, are caused a chemical imbalance in the brain. With PTSD the bad event causes the chemical imbalance and causes the brain to connect the bad event with what is happening at the present time.
Questions to ask during your assessment • Find out about the person’s sleep patterns. • Ask about the person’s ability to concentrate. • Ask if they have been getting angry or sad for small reasons. • Find out if they get surprised easily. • Ask if the person has been thinking about a bad event. If they have: o find out what happened o ask them if they feel like the bad event is still happening now o ask if the person has had difficulty remembering any details about the bad event o find out if the person has been avoiding any situations because of their fear. Formatted: o Has the person been using alcohol, illicit drugs or sleeping tablets? Often people with Bullets and Numbering PTSD will use alcohol and illicit drugs to cope with how they are feeling. o Ask if the person has lost interest in their daily life. This will tell you if they have depression. Often people with PTSD have depression too.
Things to look for during your assessment • The person with PTSD may have a tense or fearful look on their face. A person who is depressed will have a sad look on their face. • The person may be restless. • The person may have evidence of alcohol or illicit drug use (see chapter 6 ).
Things to do during your assessment • Always remember to do a physical health check.
Treatment: Medicine (biological treatment) 92
In some cases of PTSD a person will not need to take medicine. It is therefore best to try talking cures first. If talking cures have not worked, certain types of anti-depressant medicines can be used. Antidepressants should be used if: • Formatted: Bullets and The person has also got depression. Numbering • The person does not get any better despite trying talking cures for at least four weeks.
The best anti-depressant to use for PTSD is fluoxetine if available. The next best medicine is sertraline . Amitriptyline and imipramine can also be used. See appendix 1 for instructions on how to use these medicines safely.
Treatment: Talking cures (psychological treatment) It can be very healing for the person with PTSD to gradually start talking about what has happened to them. Group therapy can also be very helpful for people with PTSD (see section 3.2.1 ).
A good way to help people with PTSD is to get them to gradually start facing the situations they have been avoiding. You can show them how to do this in gradual steps. Use the same steps as those explained earlier in this chapter for agoraphobia.
You should teach all people you see with PTSD how to do relaxation exercises. Relaxation exercises can help all people with PTSD. You should also teach people with PTSD how to deal with stress. Problem solving can be very helpful. Relaxation exercises and problem solving are explained in more detail in section 3.2.
Treatment: Building the best life possible (social treatment) Social treatment can be beneficial to people with PTSD, see section 3.3 for more information. Often people with PTSD need help sleeping. Advice to help a person sleep well is given in fact sheet 2 . Finally it is very important for the person with PTSD to stay away from drinking too much alcohol and using illicit drugs.
What next? Half of all people with PTSD get better within one year. A person who has PTSD is more likely to do well if they have a supportive family who help them deal with stress. It is helpful to work with the person’s family and friends to reduce stress (see section 3.3.2 ).
Further reading 93
The Royal College of Psychiatrists website provides downloadable information for anyone who has been through a traumatic event: www.rcpsych.ac.uk/mentalhealthinformation.aspx
9.5 Medically unexplained symptoms (somatisation) In this type of mental illness, a person’s mental pain or stress is changed into physical pain. In medically unexplained symptoms there will be no evidence of physical illness despite the person having many physical examinations and investigations. In most cases the medically unexplained symptoms start at a time in the person’s life when they are experiencing a lot of stress.
What are the key features of medically unexplained symptoms? Mental distress can affect a person’s body in the following ways: • The person may experience pain or physical symptoms anywhere in their body. This is called somatisation . • The person may become very concerned that they have a serious physical illness despite being reassured by health workers that this is not the case. This is called hypochondriasis. • The person may become concerned that there is something very wrong with one part of their body when this is not the case. This is called dysmorphophobia. • Sometimes a person can be in so much mental distress that they lose control over a part of their body completely. This is called conversion-dissociation . Often the person will have lost the ability to move or feel some part of their body. These cases can often be mistaken for a serious physical illness such as a stroke. However, the results of any investigations will not be the same as for a real stroke. Hysterical seizures are a form of dissociation where the person is under so much mental distress they appear to have a seizure. Hysterical seizures are explained in more detail in section 5.2 .
People with medically unexplained symptoms will usually have seen many health workers over the years. Because of this they may have been given many different names and explanations for their problems. The following are common terms that may be used for medically unexplained symptoms: • irritable bowel syndrome • chronic pelvic pain • fibromyalgia • atypical chest pain • globus hystericus • tension headaches • hysterical seizures 94
• pseudo-seizures • chronic fatigue syndrome • myalgic encephalitis (ME).
It is very common for people with medically unexplained symptoms to also have depression or anxiety.
Who has medically unexplained symptoms? Around two in every 1000 people will have medically unexplained symptoms. More women than men develop medically unexplained symptoms. In many parts of the world this can reflect the role of women in society. Most people with medically unexplained symptoms will start having problems before the age of 30.
What is thought to cause medically unexplained symptoms? As with many other mental illnesses, a combination of events and situations can lead to a chemical imbalance in the brain. This can cause medically unexplained symptoms. It is also thought that if a child has a serious illness or knows someone who has a serious illness, then they are more likely to have medically unexplained symptoms as an adult. In these cases the child learns that having a physical illness is the best way to get help for their problems. When the child is an adult they then develop medically unexplained symptoms when they themselves have serious problems and don’t know how to get help.
Assessing someone when you suspect medically unexplained symptoms You should suspect that a person may have medically unexplained symptoms if they come to see you with any of the following things: • More than three problems. • Problems that do not fit into the usual patterns of physical or mental illness. • Problems that have lasted for more than 3 months. • They have consulted many other health workers. • No other health worker has been able to help them. • They have had previous examinations and investigations that were normal.
Questions to ask during your assessment • Make sure you ask both the person and anyone else who knows what has been happening about how the problem started. Medically unexplained symptoms happen when a person has a lot of stress in their life. The symptoms also get worse when the 95
stress gets worse, whereas physical illness starts and continues no matter what is happening in a person’s life. • Ask how long the person’s problem has been going on for. The longer a problem has been going on the less likely it will be due to a physical illness. • Ask if the person uses alcohol or illicit drugs. People with medically unexplained symptoms often use alcohol and illicit drugs to feel better. Alcohol and illicit drugs in turn make the medically unexplained symptoms worse. • Ask questions that check for depression and anxiety (see section 8.1 and 9.1 ). • • Ask about recent physical illnesses (see section 2.3 ).
Things to look for during your assessment • A worried or tense look on the face. • Any serious signs of physical illness such as jaundice (the skin and eyes having a yellow colour), fever (high temperature) and weight loss.
Things to do during your assessment Make sure that you obtain the persons previous health records or speak to as many health workers as possible who have seen the person in the past. Write down what they tell you. Make sure that all previous examinations and investigations have found no physical illness that could explain the person’s problems. Often the person with medically unexplained symptoms may not wish to speak about other health workers they have seen in the past. They may be unhappy and believe that other health workers have not done their job properly. It is very important that you do not make a mistake and miss any real physical illness. On the other hand it is also very important that you do not spend time and money repeating physical investigations that turned out to be normal.
Make sure you do your own physical health check the first time you see the person. If you have any doubts and think that the person may indeed have a physical illness then it is always a good idea to speak to a senior colleague for advice (see your crisis plan).
Treatment: Medicine (biological treatment) People with medically unexplained symptoms are often put on medicines by health workers who are trying to help but don’t really understand what is happening to the person. As people with medically unexplained symptoms will often have seen many health workers in the past, this can mean they end up on lots of medicines. All medicines can have side-effects and it can be dangerous for people to be taking medicines if they do not need them. It is very important that people with medically unexplained symptoms are not given medicines unless there is good evidence that they have a real physical illness. 96
Vitamin injections and other similar remedies for tiredness should be avoided if at all possible unless blood tests show the person has low levels of vitamins. A healthy daily routine involving eating good food and exercising is the best way to help people with medically unexplained symptoms to feel stronger.
If there is any evidence that a person with medically unexplained symptoms has depression or anxiety, then these types of mental illness can be treated with the same medicines described earlier in this chapter and in section 8.1 . Anti-depressant medicines can also be used if the talking cures explained below have not worked.
A new physical illness can of course occur in people with medically unexplained symptoms. If you have been seeing a person with medically unexplained symptoms and they start to have new physical symptoms then it is always a good idea to repeat a physical check up or get a qualified health worker to see the person again.
Treatment: Talking cures (psychological treatment) One of the most important steps in helping a person with medically unexplained symptoms is to get them to trust you and to believe that they can get better. This can be hard if they have seen many other health workers in the past who they feel have not been able to help them. As well as using the ways to counsel people as explained in section 3.2 , it can be very helpful to explain the following things to people with medically unexplained symptoms. • Just because health workers cannot find anything wrong with their body they still have a serious problem which you will take seriously. • They are not silly, lazy or imagining their problems. • These kinds of serious problems are very common. • People with this kind of problem do get better. • Though we cannot locate the exact part of their body that is causing their problems, we can teach the body to work properly again. • It can be helpful to explain medically unexplained symptoms by comparing the body to a guitar. • A guitar that is out of tune cannot play properly as the body of a person with medically unexplained symptoms cannot work properly. Even though we cannot find anything broken with the guitar, we will still need to do some work to make it play properly. The human body is much more complicated than a guitar, therefore, the work we have to do to fix medically unexplained symptoms takes longer. However, it is possible for a person 97
with medically unexplained symptoms to feel better in time. The most important thing is that the person is willing to do this work!
Try and allow enough time to talk to people with medically unexplained symptoms properly. This will help them understand that talking is the best way to get help when they have problems in their life. It is important to help people with medically unexplained symptoms to learn to deal with the problems in their life. All the techniques explained in section 3.2 can be helpful.
It can also be helpful to avoid terms like ‘mental illness’ when you are working with people who have medically unexplained symptoms. Many of these people do not associate their symptoms with mental illness. Instead it can be helpful to explain that the person’s problems are being made worse by stress. Therefore it is sensible that they learn to deal with stress if they want to feel better.
Treatment: Building the best life possible (social treatment) It is important to explain that the person needs to learn to start living with their illness whilst they are getting better. This will involve them beginning to do activities each day. Often people with medically unexplained symptoms want to wait until they feel completely better before doing things. You should explain to them that doing activities is part of the cure for their type of illness. By taking slow, gradual steps the person should start to build a daily routine. Write down (or memorise) a routine with them as explained in section 3.3.1 . You may have to start with a very small daily routine with things that the person can manage even when they feel at their worst. Once they have done this you can encourage the person that progress is possible and they can start adding activities to their routine.
If the medically unexplained symptoms cause the person to feel weak or feel pain, then physiotherapy can be useful. By practicing slow, gradual physical exercises, the person can learn that their bodies can work properly again.
What next? Often people with medically unexplained symptoms will want to see other health workers when they do not get better quickly. If possible only one health worker should work with a person with medically unexplained symptoms. This is in order to stop them spending the rest of their life having potentially dangerous investigations and drugs they do not need. People with medically unexplained symptoms have a complicated illness which takes a long time to get better. It can often take several years for them to learn to start living with their illness. It is helpful to work out a crisis plan with them so they always see the same health worker if possible. 98
CHAPTER 10 Mothers and babies
There are a number of mental illnesses that can affect women when they are pregnant or just after they have given birth. These types of mental illness are called: • Depression and anxiety during pregnancy. • The Baby Blues. • Post natal depression. • Post partum psychosis.
What are the key features of mental illness associated with pregnancy? Women can suffer from depression and / or anxiety while they are pregnant. The features of depression and anxiety in pregnant women are the same as in non-pregnant women. These features are explained in section 8.1 and 9.1.
Women can become very tearful and have mood swings about two to three days after giving birth. We call this the Baby Blues. The condition only lasts for one to two days.
In post natal depression a woman will develop the normal features of depression after she has given birth. She will also commonly worry about her baby’s health and whether she is able to cope. Sometimes the depression can be so severe the woman thinks about killing herself or her baby.
Postnatal depression most commonly happens three to four weeks after a woman has given birth.
In post partum psychosis a woman develops the features of mania or psychosis (see section 8.2 and chapter 7 ). Common features include sleep problems, confusion and the woman thinking about hurting herself or the baby. These features can change very quickly. Post partum psychosis most commonly develops about two weeks after giving birth.
Who gets this type of mental illness? • About 1 in 10 women get depression or anxiety during pregnancy. • The Baby Blues are very common. Around 7 in every 10 woman will experience the baby blues after giving birth. • About 1 in every 10 women will get postnatal depression within 6 months of giving birth. 99
• About 1 in every 1000 women will get post partum psychosis after giving birth
What is thought to cause this type of mental illness Being pregnant and giving birth can be very stressful for any woman. It is established that stress makes all types of mental illness more likely to happen. These types of mental illness are also more likely to happen if the woman has had a mental illness in the past, if she has had a miscarriage or the current pregnancy is unwanted. There is some evidence that these types of mental illness are also due to the hormonal changes of pregnancy and giving birth.
Questions to ask during your assessment People with depression, anxiety and psychosis often have problems sleeping. However all women who are pregnant or have a new baby will feel tired and have problems sleeping. In order to detect mental illness, it is therefore helpful to focus on the following questions: • Are you feeling sad or unhappy? • Do you have hope for the future? • Are you able to enjoy being pregnant or having a new baby? • Have you had thoughts about harming yourself or your baby? • If you suspect a woman may be experiencing post partum psychosis, ask the following questions: • Has anything strange been happening to you? • Are people trying to harm you or your baby? • Have you been hearing voices when there is no one around?
It is important to speak to the woman’s husband or someone who knows what has been going on. Important questions to ask include: • When did the problems begin? • How long have the problems been going on for? This will help you to decide what type of mental illness you are dealing with. For example, postnatal depression most commonly starts around two weeks after giving birth whilst post partum psychosis happens three to four weeks after giving birth. • Is the mother looking after the baby well? • Is the mother interested in her baby? • Has the mother being crying a lot? • Has the mother talked about harming herself or her baby? • Has the mother been behaving in a strange way? For example, has the mother been refusing to feed the baby? 100
• Ask about any recent physical illness ( section 2.3 ). Women often have delirium due to infections during pregnancy or shortly after child birth.
Things to look for during your assessment The woman’s face may appear sad if she has post natal depression. She may appear suspicious or angry for no reason is she has post partum psychosis.
Things to do during your assessment Make sure you test for confusion and do a physical health check . Complications after childbirth such as infections are common and women may develop delirium, which you may mistake for post partum psychosis.
Treatment: Medicines (biological treatment) If the woman has delirium or a physical illness she needs to be treated for this immediately (before treating the mental illness). The woman should be taken to a health worker who is qualified to deal with physical illness. Appendix 2 gives more information on managing physical illness.
When a woman is pregnant or breast-feeding, many medicines can seriously harm her baby. This is true for many of the medicines used to treat mental illness. Therefore, if possible use talking cures instead of medicines. Medicine in general should only be used if the talking cures are not successful, or if there are concerns that the woman may hurt herself or her baby. Medicine is not given for less serious conditions such as the baby blues. Medicine is usually always needed for serious conditions such as post partum psychosis. If a woman is thinking about harming herself or her baby she should not be left alone with her baby until she is better. She should ideally be seen by a mental health specialist such as a psychiatrist and admitted to hospital.
Before giving medicine to women, consider the following: • Always ask a woman of child bearing age if she might be pregnant before giving her any medicine. • If you are giving a woman of child bearing age medicine for mental illness, always tell her to come back and see you before she tries to get pregnant. This will allow you to choose the safest medicine for her baby. • Avoid all medicines if possible during the first three months of pregnancy. This is when a baby is at most risk of serious harm from medicines. • Always use the lowest dose of medicine possible. • Only use one type of medicine. 101
• When a woman is pregnant or breast-feeding the following medicines are the safest to use: o In depression use imipramine or amitriptyline. o In manic depression use olanzapine (other medicines for manic depression such as sodium valproate should not be used). o In epilepsy use carbamazepine. Always make sure the woman takes folic acid 5mg once daily whilst she is taking carbamazepine. Folic acid can minimise the harm carbamazepine can cause to her baby. Women with epilepsy will need to see a specialist doctor (an obstetrician) before giving birth in order to arrange having vitamin K treatment just before delivery; this prevents excessive bleeding whilst giving birth. o In psychosis use chlorpromazine, trifluoperazine or olanzapine . Stop the medicine 5–10 days before delivery so the baby is not sedated. Consult a senior health worker about restarting the medicine after the baby is born. o If a woman is breast feeding, she should take her medicine just before she feeds her baby. This will mean the medicine will be at the lowest possible dose in her body by the next time her baby needs feeding.
For information on administering these medicines safely, see appendix 1 .
Treatment: Talking cures (psychological treatment) If a woman has depression or anxiety during pregnancy, the baby blues or post natal depression then any of the talking cures explained in section 3.2 can be used. Counselling and the relaxation exercises are particularly helpful ( fact sheet 3 ).
Treatment: Building the best life possible (social treatment) Women may have very bad sleep during pregnancy or after giving birth. Use the sleep advice explained in fact sheet 2 to help any problems with sleep. Try and avoid using sleeping tablets, as these can be unsafe for the baby if the woman is pregnant or breastfeeding.
Women tend to have less support once their baby is born as all the attention is focused on her child. Make sure the woman gets enough food and rest whilst she gets better. Ask the woman’s husband and family members to help her care for her baby whilst she is getting better in the same way that they would if she had a physical illness.
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It is important to use the techniques described in section 3.3 to help a new mother build the best life possible. It is important that the woman plays with her baby and breast-feeds (provided she is not on any medicine). This will help both her and her baby in the future.
What next? Make sure the woman and her family do not worry about the baby blues . This is very normal and goes away very quickly. If a woman has the baby blues, see her again after one week to make sure she is not developing postnatal depression or past partum psychosis.
Nearly all cases of postnatal depression last for less than one month if treated correctly. If the woman has been treated with medicines, she should keep taking them for at least six months after she is better before gradually stopping her medicine (over three months). If a woman has had depression during pregnancy, postnatal depression or post partum psychosis, she is at risk of having these types of mental illness again – the next time she becomes pregnant. It is a good idea to see these women before they get pregnant again to work out a relapse prevention plan in order to stop them from becoming unwell again (see section 3.3.3 on how to do this).
If a woman has had post partum psychosis in the past and she is pregnant again, arrangements should be made for her to be monitored by a mental health specialist such as a psychiatrist during pregnancy and around the time she is expected to give birth.
Any woman on medicine for mental illness should consult a mental health specialist such as a psychiatrist before getting pregnant in order to make sure she is on the best medicine for her and the baby.
In order to prevent mental retardation (see chapter 11 ) advise pregnant women to: 1. attend antenatal clinics and take all the medication recommended 2. attend hospital for the birth of her baby so that any unforeseen complications can be quickly treated. This will mean that mother and baby remain safe and well. 3. not give birth alone so that there is always someone there to help the birth run smoothly. 4. not try and mould the babies head after it is born. This practice might damage the baby’s brain.
Further reading The Royal College of Psychiatrists website provides downloadable information for carers, professionals and people with mental health problems associated with childbirth: www.rcpsych.ac.uk/mentalhealthinformation.aspx 103
CHAPTER 11 Mental retardation
Mental retardation is not a mental illness but a condition present from when a person is very young (usually from birth). People with mental retardation do not develop as other people do. It is included in this manual as you may often be asked to assess and treat people who have mental retardation.
What are the key features of mental retardation? Mental retardation can affect a person in the following ways: • The person may have problems walking or using their hands. • The person may have problems taking care of themselves. For example, they may have problems feeding themselves, washing or using the toilet. • The person may have problems communicating. For example, they may have problems talking, reading or understanding what has been said. • The person may have problems interacting with other people. For example, a child may not be able to play with other children.
People with mental retardation are more likely to get physical illnesses (particularly epilepsy) and mental illnesses.
Who gets mental retardation? About two in every 100 people have a mild form of mental retardation. These types of people will have problems learning at school. However they will be able to look after themselves in some ways. As adults they may be able to live alone or work in the community. About five in every 1000 people have a severe form of mental retardation. These people will not be able to communicate or look after themselves.
What is thought to cause mental retardation? • If a mother has a serious infection or does not eat properly when she is pregnant, the child may suffer from mental retardation. • Sometimes, problems that occur when a child is born, can cause mental retardation. For example, a very long labour or the umbilical cord getting wrapped around the baby’s neck. • Serious physical illnesses, such as infections in the brain, can occur in young children and lead to mental retardation. • Inherited conditions such as Downs Syndrome lead to mental retardation 104
Assessing someone when you suspect mental retardation You may suspect mental retardation if a child does not grow at the same rate as their brothers or sisters and has difficulties following instructions.
You may also suspect mental retardation if a young person is not able to learn at the same rate as other students, has difficulties making friends with other young people, has difficulties with everyday tasks such as washing and dressing or shows inappropriate sexual behaviour. The more severe mental retardation is, the younger the person will be when their family notices it.
Questions to ask during your assessment If you think a person has mental retardation, the most important thing to do is to establish that their development has been slower than normal throughout their life. Ask someone who has known the person their whole life: • At what age did the child stand without support? Normally this will be between five to 10 months. Suspect mental retardation if the child was older than 18 months before they could do this. • At what age did the child begin to walk? Normally this will be between 10 to 20 months. Suspect mental retardation if the child was older than 20 months before they could do this. • At what age were they able to say two or three words? Normally this will be between 16 to 30 months. • Suspect mental retardation if the child was older than three years before they could do this. • At what age could the child feed themselves or drink? Normally this will be between two to three years. Suspect mental retardation if the child was older than four years before they could do this. • At what age could the child tell you their own name? Normally this will be between two to three years. • Suspect mental retardation if the child was older than four years before they could do this. • At what age was the child able to use the toilet? Normally this will be between three to four years. Suspect mental retardation if the child was older than four years before they could do this. • You should also ask about any problems that may have happened early in the person’s life. For example, problems in pregnancy, during childbirth or illnesses that may have developed early in life. 105
Things to look for during your assessment Notice the person’s level of attention during your interview. People with mental retardation often have problems concentrating on a conversation. However do not think that a person with mental retardation cannot understand what is being said about them. Always be polite and respectful towards them.
Most people with mental retardation look normal. However some may have physical abnormalities such as a small or large head or some other physical deformity. If the mental retardation is due to a condition called Downs Syndrome, the person will have slanting eyes, low ears, a short neck, and a single crease across the palms of their hands.
Things to do during your assessment Ask the person to do some simple speaking, reading or writing tests that you would expect them to be able to do easily. For example, a child of three should be able to tell you their name. If the child is at school it is very helpful to get a teachers report on the child’s development. People with mental retardation are more likely to get physical illnesses. It is therefore very important that you do a physical health check as part of your assessment.
What is the treatment for mental retardation? If you think a person has mental retardation it is important to do two things:
1. Arrange for the person to have their hearing checked by a specialist. Often people with hearing difficulties can appear to have mental retardation. Once the hearing problems are fixed the person may be able to develop normally.
2. Arrange for the person to have thyroid function blood tests. Sometimes people with under active thyroid glands can appear to have mental retardation. If this condition is corrected the person may be able to develop normally.
Treatment: Medicines (biological treatment) Medicines should only be used if the person with mental retardation has seizures or an under active thyroid gland. In these rare situations the person should be seen by a specialist in order to decide on the best medicine. Apart from these situations medicine should not be given to 106
people with mental retardation . There is no cure for mental retardation and things such as brain tonics, vitamins or other medicines are only likely to make the person unwell. People with mental retardation are also more likely to develop dangerous side-effects to medicines.
If a person with mental retardation displays different or difficult behaviour, always suspect that they may have developed a physical illness and do a physical health check. Remember, a person with mental retardation may not be able to tell others they are in pain and so they may communicate by being agitated or aggressive. If no physical illness can be found to explain their behaviour, use the techniques described in chapter 16 for managing difficult behaviour rather than giving regular medicine.
Treatment: Talking cures (psychological treatment) The family should communicate with the person even if they feel it is pointless. For example, they should talk to them in very simple language or read simple storybooks to them. If the person is able to begin speaking more, the family should then increase the level of their speaking and story telling.
It can be helpful to teach relaxation exercises to the person with mental retardation, so they can learn to deal with stress ( fact sheet 3 ).
Treatment: Building the best life possible (social treatment) Social treatment is the most important way to help a person with mental retardation and their family. It is best to start with simple, small tasks that the person can learn before moving on to more complex activities. It is a good idea to separate tasks into small parts that can be learned step-by-step. For example, the task of washing can be separated into the following steps. 1. Holding a container of water 2. Wetting the body 3. Applying soap to the body 4. Rinsing off the soap from the body 5. Drying the body
A family member should help the person with mental retardation to learn each step before putting the steps together. Once all the steps are learnt in the correct order, the task should be practised for at least two weeks before the next activity is learnt. Family members should always give the same clear advice to the person with mental retardation, to prevent them from getting confused.
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Family members should find activities that allow them to spend time with the person with mental retardation, but which are also useful. For example, a person with mental retardation could learn to help clean the family home. This will help the person feel valuable and will reduce the stigma they experience. Family members should always give rewards or praise when the person with mental retardation does something well. This will encourage them to keep making progress. The person with mental retardation should be taught how to behave well towards others. Family members can teach them how to greet others, how to ask for permission to use things and how to behave appropriately towards the opposite sex.
Education is as important to a person with mental retardation as to anyone else. Some schools work specifically with people with mental retardation. Often people with mental retardation are able to work as they get older. Jobs with simple, repetitive routines may be the ideal kind of employ ment.
What next? Having a family member with mental retardation can be very stressful. If possible the whole family should help. This will stop the parents from becoming too stressed. It can be very helpful to refer the family to a community support group if there is one in the area.
The family needs to be told that there are no magic cures for mental retardation and that they shouldn’t waste their money on any cures that they are offered. The family also needs to be realistic about how much progress can be made. The more severe the mental retardation, the less progress the person will be able to make. However it is also important to remain positive and encourage family members.
With the support of a loving family, a person with mental retardation can make progress and have a happy , worthwhile life.
Further reading The Royal College of Psychiatrists website provides downloadable information for carers, professionals and people with mental retardation: www.rcpsych.ac.uk/mentalhealthinformation.aspx 108
CHAPTER 12 Mental illness and young people
Young people can suffer from nearly all of the different mental illnesses covered in the other parts of this manual (apart from conditions that only affect the elderly such as dementia). This chapter explains the types of mental illness that have slightly different features in young people and some other types of mental illness that are only found in young people.
Assessment of young people The most important thing to do when assessing any young person is to check to see if they have a physical illness. This is because young people are much more likely to have a mental illness that is caused by a physical illness. Epilepsy and seizures (see section 5.2 ) are especially likely to be caused by a physical illness. Children are also much weaker than adults and are much more likely to die from a physical illness.
Signs that a child is physically unwell include irritability, drowsiness, poor feeding, seizures, fever (or feeling hot to touch) and weak limbs. Physical observations can be done by anyone and are an extremely useful way of detecting if a child is physically sick. The following table shows the normal physical observations for children of different ages.
Breathing rate Pulse (beats per Systolic blood pressure Age (years) (breaths per minute) minute) (mmHg)
Less than 1 30–40 110–160 70–90
1–2 25–35 100–150 80–95
2–5 25–30 95–140 80–100
5–12 20–25 80–120 90-110
>12 15–20 60–100 100–120
A capillary refill test (see section 2.5) of more than 3 seconds in a child of any age shows that they are dehydrated.
If you discover that the child has a physical illness, it needs to be treated immediately (before treating the mental illness). Refer the child to a qualified health worker as soon as possible. If you 109
are the most senior health worker available, appendix 2 explains the steps you can take to save a child’s life.
Treatment of mental illness in children In general, medicines for mental illness should not be given to people under 18 years of age. In young people the brain is still developing and it is thought to be very sensitive to the effects of the powerful medicines used to treat mental illness. Young people are also more likely to suffer from serious side effects from medicines such as delirium (see chapter 5.1 ). The main exception to this rule is epilepsy, where there is good evidence that the medicine used is safe and that young people benefit from treatment . When medicine is given to young people always start with at least half the dose you would do in an adult and wait twice as long before increasing the dose . The best medicine to use to treat epilepsy in young people is carbamazepine . See appendix 1 for instructions on how to use this medicine safely.
12.1 Enuresis and encopresis When a child urinates either during the day or night and wets their clothes or bed sheets – this is called enuresis. Encopresis is when a child passes faeces and soils their clothes or bed sheets.
What are the key features of enuresis and encopresis? It is normal for a child to wet themselves during the daytime up to the age of 3 years. It is also normal for a child to wet themselves during the night up to the age of five years. If a child wets themselves beyond these ages, the child has enuresis .
It is normal for a child to pass faeces in their clothes or in bed up to the age of four years. If it happens when a child is over four years, the child has encopresis.
Who gets it? Both enuresis and encopresis are more common in boys. About five in every 100 children will have enuresis and about five in every 100 children have encopresis.
What is thought to cause it? Enuresis and encopresis are most commonly caused by stress such as school problems, arguments within the family or the birth of a younger brother or sister. Less common causes include constipation, urine infections, diabetes, child abuse and neurological problems. Enuresis can also occur when the development of a child’s bladder control is delayed. It is important to note that this is not the same as mental retardation where there is a delay in the development of many areas (see chapter 11 ).
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Questions to ask during your assessment • How old is the child? • When does the problem happen? During the day, night or both times? • Has the child ever learned to go to the toilet properly? If not, the problem is likely to be a delay in the development of controlling urine or faeces. • Has there been any stress in the child or family’s life recently?
The child will probably be very embarrassed to talk to you about what has been happening. Make sure you speak to them in a very gentle, friendly way. It can be helpful to speak about other fun things first before asking them the following questions: • Has there been anything worrying them? • Does it hurt or sting when urine is passed? This suggests a urine infection. • Is it painful when faeces is passed? This suggests constipation. • Ask the questions that help you to identify child abuse (see section 12.5 ).
Things to do during your assessment • Look at the child’s lower back and watch the child walking. If the child appears to be walking abnormally, this can suggest a rare neurological disorder. • If possible test a sample of the child’s urine at the nearest laboratory. The presence of glucose or • ketones indicates diabetes. The presence of leucocytes, nitrites, blood or protein indicates a urine infection. • Look for any signs of abuse (see section 12.5 ).
What is the treatment? If diabetes, a neurological disorder or child abuse is suspected, the child should be referred to a specialist doctor.
Treatment: Medicines (biological treatment) If constipation is thought to be present, advise the fami ly to make sure the child drinks enough water and eats lots of fruit and vegetables. The fibre in the fruit and vegetables will aid the child’s digestion. Only give stool softeners or laxatives if passing faeces is painful. If a urine infection is present, treat with a course of antibiotics and advise the child to drink plenty of water. In all other cases, medicine should not be used as it can make the problem worse.
Treatment: Talking cures (psychological treatment) This is the best treatment for enuresis and encopresis. The following simple advice should be explained to the child’s family. If practised regularly it can teach a child to control passing urine and faeces. • Ensure the child goes to the toilet just before bedtime. 111
• Encourage the child to go to the toilet regularly, for example every two hours. This will mean the bladder is always empty. Once this controls daytime wetting, get the child to gradually increase the time between trips to the toilet. • Ask the child to stop whilst passing urine, then hold on for a few seconds before finishing urination. This activity strengthens the muscle that controls the flow of urine. • Praise the child for each day or night that they go to the toilet normally. A good way to reward children is to use a star chart. After each day or night that they go to the toilet normally, the child earns a star on a piece of paper. After an agreed number of stars have been earned, the child gets a reward such as a favourite food. • Do not get angry if the problem continues, this will only cause stress to the child and make things worse. Instead say you are happy that they have tried their best and that things wi ll improve in the future. • If the bed-wetting continues, wake the child in the middle of the night and make them go to the toilet. Make sure the child is fully awake when it goes to the toilet. • It is also important to tackle any stress within the family that may be causing the problem.
What next? Explain to the fami ly that enuresis and encopresis are very common and are simple to treat provided they follow the advice given above.
Further reading The Royal College of Psychiatrists website provides information on enuresis and encopresis in the ‘young people’ section of the website: www.rcpsych.ac.uk/mentalhealthinformation.aspx 112
12.2 Attention deficit hyperactivity disorder (ADHD)
ADHD is when a child has too much energy and cannot sit still and pay attention.
What are the key features of ADHD? • The child is restless and often unable to sit through an entire lesson at school. • The child talks too much and interrupts others. • The child is easily distracted and cannot complete tasks. • They can be impulsive – meaning they do very silly things without thinking of the consequences. • The child has problems concentrating. • The child is impatient. • They may be forgetful and lose things.
All children are restless, excited or naughty from time to time. However a child with ADHD is much more restless and excited than a normal child of the same age. In ADHD the features listed above will be present for at least six months and in all situations in the child’s life. For example if a child is only restless in one situation (at school) and can be calm at home, then the child does not have ADHD.
The behaviour of a child with ADHD will be very annoying to teachers and classmates. This means that the child gets into problems at school and will often not have many friends. It is important to recognise that a child has ADHD and is not simply being naughty.
Without the correct treatment, children with ADHD can grow up to have problems with alcohol, illicit drugs or get in trouble with the police.
Who gets ADHD? About one in every 100 children develop ADHD. Boys are three times more likely to get ADHD than girls.
What is thought to cause ADHD? Stress within the family is thought to be a major cause of ADHD. Having a family member with ADHD also increases the risk that others in the family will have ADHD.
Questions to ask during your assessment • Ask about complaints from school or friends. It is important to make sure the child shows the features of ADHD in all situations. 113
• Find out how long the problem has been going on for. All children behave in a difficult way for a few weeks or a few months. The problems need to have been there continuously, for at least six months for a child to have ADHD. • Ask about what the family have done to try and control the child’s behaviour. Often children with • ADHD will have been severely beaten by family members who think they are being naughty. Be aware that child abuse may be happening as a result of the child’s behaviour (child abuse is covered later in this chapter). • Ask the child if they have any problems or worries. A child with ADHD will know that something is wrong and that their behaviour is upsetting their family. • Ask the child if they have any problems sitting still and concentrating on things a normal child would like to do (for example watching television). • Make sure the child’s behaviour has the features of ADHD described above and not conduct disorder (see section 12.3 ).
Things to look for during your assessment The child may be restless and unable to sit still whilst you talk to them. They child may interrupt other people. Look for any signs of physical abuse towards the child (see section 12.5 ).
What is the treatment for ADHD? It is important to explain to both the family and the child what the problem is. Most families will feel greatly relieved to know their child has a health problem that can be treated.
Treatment: Medicines (biological treatment) Do not use sedative medicines, this will only make the child drowsy and make their concentration worse. The psychological and social treatments explained below should always be used first. If they do not work, a medicine called methylphenidate may help in some cases. This medicine should only be given by a senior mental health worker with experience in child mental health (for example a child psychiatrist).
Treatment: Talking cures and building the best life possible (psychological and social treatment) Ask parents and teachers to do the following things: • Avoid punishing the child as he or she is not deliberately behaving in a bad way. • When the child behaves badly, remain calm. The best way to deal with bad behaviour is to use the ‘time out’ technique (see next page). • Give praise and reward when the child behaves in a good way. 114
• Do not give too many commands as this will confuse the child with ADHD. Complex tasks should be broken down into small steps. For example, if a child with ADHD is told to “pick up your toys, wash yourself and go to bed” they will get distracted before all the tasks are finished. Instead the child should be told to pick up their toys, once this is done successfully they should be praised and have a short rest before being told to do the next activity. The child should be watched whilst doing a task. If they become distracted they should be reminded in a calm but firm manner, to go back to the task. • When giving instructions look directly at the child and speak in a clear, direct and calm manner. Using too many words or shouting will only confuse the child. Ask the child to repeat instructions to make sure they have been understood. Teachers can write instructions for homework in a book to improve communication between the home and school. • Reduce stimulation to the child. For example, the television should not have the volume turned up too loudly. The child can be given one toy to play with rather than lots of toys. In school, the child should sit at the front of the class away from doors and windows if possible. This will mean that the teacher can keep a close eye on them and will also stop them from being distracted by other classmates. • Establish a regular routine of bedtime and activities for the child. Regular sport or physical activity is very helpful in getting rid of the child’s extra energy. Let the child decide on the activities. A chart can show the child each day’s activities so that they do not forget what they have to do. • Plan the family’s activities so that the child is not taken to crowded places like weddings and markets. • If the child is taken to a crowded place, a family member should be prepared to take them home when they become too excited. • The child should be listened to regularly. A child with ADHD will feel unhappy because they are not like other children. Reassure the child that they are not bad. Explain that you understand why they are behaving in this way. Encourage the child that you are working with them and that slowly their behaviour will improve.
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Using the ‘time-out’ technique In the ‘time out’ technique a child who has behaved badly is calmly placed in a quiet place and ignored by the rest of the family. Quiet places can be a room with very few things in it, or a chair in the corner of the room. A family member should calmly explain to the child why they are being moved to the quiet place. Apart from this the family should say nothing else to the child. If the child tries to escape from the quiet place a family member should calmly place them back in the quiet place again.
At first a child may try to escape many times until they learn that they cannot get attention or make the family angry by doing this! The length of time the child should be made to stay in the quiet place depends on their age. For example, a child that is five years old should be made to stay in the quiet place for 5 minutes, a child that is 14 should be made to stay in the quiet place for 14 minutes. Once the child has remained in the quiet place for the correct amount of time, a family member needs to speak to them once again and explain why this has happened. At this point the child should apologise for behaving badly. If they do not they should remain in the quiet place until they do.
Once the child has apologised, it is important that the family and the child become friends once more by hugging or saying kind things. As well as using ‘time out’ it is important to use the technique of ‘time in’. This means that the family should spend time playing or talking and listening to the child each day. ‘Time out’ and ‘time in’ gradually teach a child that behaving well leads to good things happening to them.
What next? Most children with ADHD will ‘grow out’ of their problems by the time they become adults. About one in every five children with ADHD will continue to have the same problems as an adult.
Further reading The Royal College of Psychiatrists website provides information on ADHD in the ‘young people’ section of the website: www.rcpsych.ac.uk/mentalhealthinformation.aspx
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12.3 Conduct disorder
All children will behave badly at some stage in their development. Conduct disorder is when bad behaviour is so severe that it can be considered a health problem to the child.
What are the key features of conduct disorder? Conduct disorder is different from normal bad behaviour in the following ways: • It is present for at least six months. • The child will be in serious trouble, for example they may have broken the law or got in trouble with the police. • The child will be seriously violent. For example, their behaviour may have injured themselves or someone else. • The child’s behaviour will prevent them from developing a good future. For example, they may refuse to go to school.
Who gets conduct disorder? Conduct disorder is more common in boys than girls. In many parts of the world it is the most common reason for a child being taken to see a mental health worker.
What is thought to cause conduct disorder? Many people feel these children are simply ‘bad’. This is not true. Children with conduct disorder have learned from others how to behave in a bad way. For example if a child grows up in a house where other family members are violent they will also learn to be violent towards others. If a child has been neglected it will learn that the only way to get attention is to behave badly. If different members of the family discipline the child in different ways, the child will become confused and not understand what is right or wrong.
Questions to ask during your assessment • Find out from the family how the child has been behaving badly. Make sure the child does not have the features of ADHD (see section 12.2 ). • Ask the family how each member disciplines the child. You should find out if the child has been beaten or if different members of the family discipline the child in different ways. • Ask the child what they think the problem is. Understanding the child’s point of view may help you come up with a solution to the problem. 117
• Ask the family and the child what they are willing to do to sort out the behaviour. This will tell you how hard the parents and the child are prepared to work to sort out their problems.
Things to look for during your assessment • Observe the family and the child together. You may be able to sense a lot of anger from different family members towards the child. Look at the child’s face when others are talking, it may look sad or angry. These observations may show you which family member needs to do most work to help the child. • Look for any signs of physical abuse towards the child (see section 12.5 ). • Look for any signs that the child might have ADHD instead of conduct disorder.
Treatment: Medicines (biological treatment) Do not use medicines for conduct disorder, even if the family feels the child needs to be calmed down. Explain to the family that sedating medicines can be dangerous to children.
Treatment: Talking cures and building the best life possible (psychological and social treatment) The following steps can be used to help teach any child to behave well. They are the best treatment for conduct disorder and should be followed by all members of the family. • Praise or reward any good behaviour. The family should be very clear why they are praising the child. • Always have a clear, calm but firm manner when asking the child to do things. If family members lose their temper, it will be impossible for the child to learn how to control their own temper. • All members of the family should agree to behave towards the child in the same way, at all times. If people behave differently in any way towards the child, they will become confused and stop behaving well. • The family must never use violence to control the child’s behaviour. If they do the child will learn that violence is the way to sort out their problems. The ‘time out’ technique explained earlier in this chapter has been shown to be more effective than violence in controlling children’s behaviour.
What next? Explain to the family that their problems are common and that their child is not simply bad or evil. 118
Teaching a child to behave well takes a lot of patience and hard work. However, if everyone in the family follows all of the steps explained above, at all times, it is possible for the child to make good progress and learn to live a normal life.
Further reading The Royal College of Psychiatrists website provides information on conduct disorder in the ‘young people’ section of the website: www.rcpsych.ac.uk/mentalhealthinformation.aspx
12.4 Depression in young people
What are the key features of depression in young people? Depression in young people has many of the same features as depression in adults (see chapter 8). However depression in young people is more likely to have the following features: • Headaches or aches and pains anywhere in the body. • Problems concentrating or difficulties at school. • Having problems sleeping. • Having poor appetite. • Becoming moody or aggressive. The young person may stop speaking to their family or friends. • Feeling that life is pointless. Young people are at an increased risk of killing themselves. In some parts of the world, suicide is the third most common cause of death in young people. • Using alcohol or illicit drugs.
Who gets it? About one in every ten young people become depressed. Depression is equally common in boys and girls.
What is thought to cause it? Depression in young people is usually caused by stress. Children will often have different reasons for feeling stressed compared to adults. Common causes of stress in young people include family problems, difficulties at school, abuse (see section 12.5 ) or loneliness.
Questions to ask during your assessment • Ask the family about any changes in the young person’s behaviour. • Ask the young person if they have any worries. • Ask the young person about their sleep, appetite and concentration. • Ask the young person if they are using alcohol or illicit drugs. 119
• Make sure you ask the young person if they have ever felt like killing themselves. If they have – speak to a senior colleague (see your crisis plan).
Look for signs of abuse during your assessment ( section 12.5 )
Treatment: Medicines (biological treatment) Medicines should only be used if the talking cures and social treatments explained below do not work. Medicines for depression in young people should only be given by a senior mental health worker such as a child psychiatrist.
Treatment: Talking cures (psychological treatment) All of the techniques described in section 3.2 can benefit young people with depression.
Treatment: Building the best life possible (social treatment) All of the techniques described in section 3.3 can also benefit young people with depression.
What next? Depression is very common in young people. If young people can learn how to cope with stress they can avoid having problems such as depression later on in life.
Further reading The Royal College of Psychiatrists website provides information on depression in young people in the ‘young people’ section of the website: www.rcpsych.ac.uk/mentalhealthinformation.aspx
12.5 Child abuse This is when a child’s health or development is hurt by the actions of another person. Child abuse is not a mental illness but it is covered in this manual as many health workers will be asked to see children who have been abused.
Child abuse can happen in three ways: 1. Physical abuse. Most parents may hit their children now and again to discipline them. However if the physical punishment is severe or happens too often, it can damage the child’s health. 2. Emotional abuse. This is the most common but least understood form of abuse. Here a child is neglected or put under a great deal of stress. Common forms of emotional abuse are not giving enough food, medicine or love to a child. 3. Sexual abuse. This is when an adult uses a child for their own sexual 120
pleasure.
Abuse makes the child more likely to develop mental and physical health problems. In severe cases abuse can lead to the death of a child.
What are the key features of child abuse? A health worker should suspect child abuse when a child: • is very afraid, sad and withdrawn. The child may not want to play with other children. • performs poorly at school or runs away from school or home. • is aggressive and bullies other children. • starts lying, stealing, using drugs or alcohol. • knows more about sex than you would expect for their age. The child may also touch or play with sexual parts of their body. • has repeated painful urine infections. • starts wetting the bed or soiling their clothes after previously being able to control when they go to the toilet. • is constantly losing weight, is sick all the time or is not growing as would be expected. • goes back to behaving like a younger child. For example, a six year old child may go back to behaving like a three year old.
Who suffers from child abuse? Child abuse is more common than you might think. This is because children are often scared or embarrassed to talk about what has been happening. Child abuse happens to both boys and girls, including sexual abuse. Most children are abused by people they know rather than by a stranger. Most commonly children are abused by a male relative.
Questions to ask during your assessment • Find out if the child is being hurt in any way. If so, find out in what way the child is being hurt and how long the problem has been going on for. • Find out how many people know what has been going on and what has been done about the problem. • Find out which adult is responsible for the child. If this is the person that is abusing the child, find out if someone else could take responsibility for the child instead.
It is difficult to speak to children about abuse because they are usually very frightened. If possible an experienced health worker should talk to the child. They will spend time with the child making 121
them feel comfortable before asking the child if anyone has been hurting them. The child should be interviewed with their mother or another adult who is definitely not abusing them.
Do not doubt a child if they tell you they are being abused. The safest thing to do is to take the problem seriously!
Things to look for and do during your assessment Try and do a physical examination. Children who have been abused are very frightened about being physically examined. Explain what you are doing and have an adult that the child trusts with you. Do as much of a physical examination as possible and look for injuries to the child’s body or inflammation around the sexual organs and anus. Write down your findings clearly in the records, they may be needed later by the police.
What next? If you suspect a child is being abused, speak to a senior colleague at once (see your crisis plan). They will decide on whether to involve the police or a social worker. If the child’s life is in danger it will be need to be moved to a safe place immediately. This could be a relative, a hospital or an organisation that works with children.
Often a family will not be aware that their behaviour is hurting the development of their child. Most people who abuse children stop once their behaviour has been addressed by a professional.
Make sure you speak to the child about what has been happening. Children who have been abused often feel very guilty and they need to be told that the abuse is not their fault. A crisis plan (see section 3.2.4 and fact sheet 1 ) should be made with the child so that they know what to do if the abuse starts happening again. The child should know where to go to get help. It is important that the child learns how to control their anger about what has been happening. Relaxation exercises ( section 3.2.3 ) are useful for this. The family will need to show lots of love towards a child that has been abused, but at the same time take care with physical contact – which the child may find upsetting.
Further reading The Royal College of Psychiatrists website provides information on child abuse in the ‘young people’ section of the website: www.rcpsych.ac.uk/mentalhealthinformation.aspx
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12.6 Specific learning difficulties (SLD)
All of the conditions described in this chapter can lead to a child having problems at school. Specific learning disabilities are when a child has a problem in only one area of learning at school.
What are the key features of SLD? The child will have a problem with only one area of learning such as such as reading, writing or mathematics. This is different from mental retardation ( chapter 11 ) where the child will have problems in most areas. Children with SLD can also have problems telling left from right, they may be clumsy and have difficulty following instructions.
Who gets it? About four in every 100 children have SLD. It is more common in boys.
What is thought to cause SLD? People with SLD are thought to understand information in a different way to the rest of the population. This means they have problems learning in the same ways as other people in certain areas.
Questions to ask during your assessment • Find out from the family what difficulties the child is having at school. • Ask if the child is able to tell their left from their right. • Find out if the child is ever clumsy or has problems following instructions. • Ask the child what subjects at school they like and dislike. Usually a child with SLD will dislike the subject they are having problems understanding.
Things to look for and do during your assessment: • Sometimes children with sight or hearing problems can appear to have SLD. Always check the child’s hearing and vision if you think they have SLD. If a child is able to answer your questions, their hearing is probably normal. Check the child’s vision by asking them to describe what they see outside the window. • Look at the child’s handwriting. In SLD it is often untidy and certain letters that look the same may be reversed. For example the letter ‘d’ may be used instead of the letter ‘b’. • Check to see if the child can follow instructions or is clumsy by asking the child to tie their shoelaces.
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What is the treatment? Medicines should not be used to treat SLD. Ideally the child should be sent to an education specialist who can make sure the diagnosis is correct. If specialist help is not available, the parents can help the child with homework and study. The child may need to be moved down to a lower class. If the child seems unable to learn in school, they should be sent to a vocational school where they can learn a skill that will help them find a job later in life.
What next? Children with SLD are often thought to be stupid or lazy. It is important that you explain to the child and their family that this is not the case. With the right help they can do as well as other children.
Further reading The Royal College of Psychiatrists website provides information on SLD in the ‘young people’ section of the website: www.rcpsych.ac.uk/mentalhealthinformation.aspx 124
CHAPTER 13 Mental illness and old age
For the purposes of mental health, old age is considered to be anyone over the age of 65 years old. All of the mental illnesses described in chapters 5 to 9 can occur in old people. The most common types of mental illness in old people are depression, delirium, and dementia. In assessing any old person it is important to: • Check for confusion. • Do a physical health check. • Test the person’s sight and hearing. Sight and vision problems can often present with the same features as mental illness in old people. A basic way of doing this is described in section 12.6 . If you feel the person needs a more detailed test, refer them to a specialist. • Ask if the person has thought about harming themselves. It is estimated that one in five of all suicides happen in old people.
The body changes as we get older and gets more sensitive to the effects of medicine. Old people are at risk of dangerous side-effects from medicines (dizziness, falling over). When giving medicines for mental illness in old age, always keep to the following rules: • Start low and go slow. Start at half the dose you would normally use in an adult. Wait twice as long as you normally would to see if the medicine is working before increasing the dose. • Always use one medicine rather than two. • Always find out what other medicines the person is taking. Often they will not be able to remember. • Therefore ask them to bring all of their medicines to their appointments. Older people are more likely to be on lots of medicines for physical illness. Always check to make sure that these medicines are not causing their mental illness or that any new medicine you give will not cause a dangerous interaction. • If an old person is depressed, use a low dose of sertraline rather than amitryptiline. This should result in fewer side-effects. • If an old person has psychosis, use a low dose of haloperidol rather than chlorpromazine or olanzapine. This should result in fewer side-effects.
Further reading The Royal College of Psychiatrists website provides information on mental illness associated with old age. Resources are available for people who are worried about their mental health, carers and professionals working with older people with mental health problems: www.rcpsych.ac.uk/mentalhealthinformation.aspx 125
CHAPTER 14 Headaches
Having a headache is not a mental illness. However headaches are included in this manual as they are extremely common and you are likely to see a lot of people with this problem.
Types of headache and appropriate treatment
First episode of headache Only rarely will a person come for help during their first ever headache. The following are serious causes of first ever headaches: • Meningitis / encephalitis (infection in and around the brain) and subarachnoid haemorrhage (bleeding within the brain). These headaches will be felt all over the head and the person will have neck stiffness, drowsiness and confusion. These headaches need to be referred at once to a physical health specialist (see your crisis plan). • Headache after head injury . If the person has any drowsiness or confusion shortly after a head injury they need to be referred at once to a physical health specialist (see your crisis plan). Otherwise explain these headaches will usually go away after about 2 weeks. It may be worth trying a simple painkiller like paracetamol (1000mg given up to 4 times daily). However you should also explain to the person that painkillers often do not work for these types of headache. • Malaria. As well as headache the person will have the other signs of malaria; fever, shakes, diarrhoea, a bitter taste in the mouth and flu-like symptoms. Here the person needs to be treated for malaria rather than headache. • Sinusitis. Here the person will have pain beneath their eyes, the skin over this area may be tender and they may have a runny nose. These headaches are made worse by bending over. In most cases these headaches will go away with no treatment. If the headache has lasted for more than one week, treat with a one week course of amoxicillin. Give 250mg three times daily, double this dose if the infection is severe. Always check to make sure the person is not allergic to penicillin. • Glaucoma . This occurs in elderly people. They will have pain in one eye, the eye will be red and the pupil will not react to light. The person may also feel like vomiting. The person needs to be referred immediately to an eye specialist.
Headaches that occur in ‘attacks’ The person will have attacks of these headaches from time to time. However, between attacks the person will feel fine. Types of these headaches include: 126
• Migraine. These headaches are thought to be quite common, about 3–7% of the population will suffer from migraine at any one time. Here the person will have problems with their sight for about 30 minutes. Typically they will see spots or wavy lines. After this they will have a throbbing headache on one side of the head. Often they will feel nauseous and vomit. During attacks the person should take metoclopramide 10mg, as well as paracetamol 1000mg, or aspirin 900mg. These medicines should not be taken between attacks. Advise the person to avoid cheese, caffeine (tea, coffee, coke), alcohol and stress as these can cause attacks. Once it has been explained to them that migraine attacks will not harm them, most people can live without medicine. If they get more than two attacks each month you can try amitriptyline or propranolol. See appendix 1 for instructions on how to use these medicines safely. • Cluster headaches. These headaches are very rare, only 0.1% of the population will suffer from these headaches at any one time. These headaches happen very quickly. One eye will become very painful and watery. The person will have an attack each day for several weeks. After this they will have a time when they have no attacks. The treatments that have the best evidence for cluster headache are sodium valproate, verapamil and sumatriptan. If you think a person has cluster headaches, consult a senior health worker.
Headaches that develop slowly over a few weeks Giant cell arteritis is very serious and can cause this type of headache. This type of headache is extremely rare in people under 55 years old. People that develop this type of headache will present with a headache that has lasted a few weeks. The blood vessels between the eyes and the hairline will be painful to touch. The person will need to be started on prednisolone 40mg and referred to a medical doctor (see your crisis plan). An ESR blood test will confirm the diagnosis.
Headaches that have been present for several months (chronic headaches) These are the most common types of headaches you will be asked to see. • Raised intracranial pressure. This is the only serious cause of chronic headache. These headaches are worse on waking in the morning and on lying down. The pain from the headache is usually not severe. The person may also complain of vomiting. People with raised intracranial pressure need to be referred to a medical doctor for further tests. • Stress / tension Headaches. This is the most common type of headache you will see. In some populations up to 70% of the population will suffer from these headaches at any time. The pain will not be ‘throbbing’ and will be over both sides of the head. The pain will also get worse when the person is stressed or angry. You should suspect stress headaches if a headache does not match any of the other headache 127
patterns described in this chapter, or if the headache does not improve with medicine. Stress headaches should not be treated with medicines. Head massage and relaxation exercises (section 3.2.3 ) are the best treatment. If a person has any of the features of depression such as sadness, poor sleep and loss of interest (see section 8.1 ) then it is reasonable to treat them with amitriptyline . See appendix 1 for instructions on how to use this medicine safely. If the headaches do not get better after being on a full dose of amitriptyline for 6 weeks, slowly reduce and stop the medicine. • Medicine misuse headache. This is when a person has been using too many painkillers in order to control a mild headache. This is also a very common cause of headache. Up to 5% of the population may be suffering from this type of headache at any time. Nearly all medicines can cause headaches as a side-effect, even those used to treat headaches! Common medicines that cause misuse headaches are paracetamol, codeine, diazepam (valium) or diclofenac (volterol). Explain to the person that medicine is making their headache worse and that it will need to be stopped. If a person is on high doses or lots of different types of medicine this may have to be done slowly. In many cases the person will be unhappy that their medicine is being stopped. Explain that having a non serious headache will not harm the person whereas being on too many medicines will do. Also explain that it may take a few months for them to start feeling better as the effects of medicine can last a long time. If a person has any of the features of depression such as sadness, poor sleep, loss of interest (see chapter 8 ) then treat them with amitriptyline as described above, otherwise avoid medicines. Medication misuse headaches can be prevented by warning people not to use painkillers for more than 10 days each month. • Trigeminal neuralgia. In this rare type of headache, the person will have intense pain in their face whilst touching their skin, the pain will last for a few seconds. Trigeminal neuralgia is most common in men over 50 years old. Carbamazepine can be used to treat this condition. Give carbamazepine 100mg one to two times daily. Do not increase the dose by more than 100–200mg every 2 weeks. Usually patients with trigeminal neuralgia need 200mg, three to four times daily.
Assessment of headache Ask the following questions about any headache: • Is this the first time the person has had the headache? • How long has the headache been going on for? • Is the headache present all of the time or does it come and go in attacks? • Where in the head is the pain? Is the pain on one side of the head or both sides? • What else is happening apart from the headache? Is there any fever, neck stiffness, drowsiness, nausea, vomiting or eye problems? 128
• Has anything helped the headache such as pain killers? • Does anything make the headache worse such as lying down, bending over or feeling stressed?
Physical health check for anyone with headache If you are qualified, a full neurological examination should be done on anyone with headache. However the basic parts of this examination can be done by any health worker. • Ask the person to move their chin down so that it touches the chest, this tests for neck stiffness. • Gently press the area where the person complains of headache. Press the area between the eye and the hairline as well as below the eyes. This will test for giant cell artiritis, sinusitis and trigeminal neuralgia. • Shine a light into each eye. Normally the dark circle in the centre of the eye (the pupil) will react and get smaller to light. If you don’t have a light you can still do this test. Hold your finger just in front of the person’s nose. Ask them to look at something far away such as the wall in the room, and then ask them to look at your finger. The pupils should become small as the person looks from the distant object to your finger. If there are any problems with this test, ask a senior colleague for advice.
The different types of headache described above can seem very confusing at first. However don’t worry! With practice you will soon be able to quickly recognise and treat headaches.
Remember that everybody gets headaches from time to time. Very few headaches are serious or need medicine. In fact, if you discover a person has a serious headache they will most often need to be referred to a specialist health worker rather than being given medicine. Most headaches only need simple painkillers like paracetamol or aspirin. These medicines should not be taken regularly and should be stopped once the headache is over.
Often people are put on lots of medicine for headaches and in the end the medicine ends up making the headaches worse (see medicine misuse headache). Make sure you do not fall into this trap! If a person’s headache does not get better after a few weeks of being on medicine, the medicine should be stopped. Consider whether the person has a serious headache that needs to be seen by a specialist or if the person has a non serious headache that will be okay without medicine. Never just add a second or third medicine in the hope that it will help, usually this will just make the headache worse. 129
Further reading The following websites provide more information on headaches for professionals: • The International Headache Society www.i-h-s.org • The World Headache Alliance www.w-h-a.org • The World Health Organisation www.who.int/mediacentre/factsheets/fs277/en/ 130
CHAPTER 15 Emergencies due to medicines
Sometimes people can have a severe reaction to a medicine. This chapter lists possible reactions to medicines used to treat mental illness. It should help you to identify these reactions so that you can alert a senior health worker. If you are able to prescribe medicines yourself, it also advises on the best treatment for each reaction.
15.1 Acute dystonic reactions This is a severe reaction to anti-psychotic medicine.
Who gets it? About one in every 10 people who take anti-psychotic medicine will have an acute dystonic reaction. Acute dystonic reactions usually happen around two days after starting anti-psychotic medicines for the first time.
What is it like? The person will have severe stiffness in the neck, tongue or jaw. The eyes may roll from side to side. The person’s back can also arch or bend.
What do you have to do? 1. Stop the anti-psychotic medicine. 2. Give an anti-cholinergic medicine such as procyclidine 5mg or benzhexol 5mg. If the person can swallow give the medicine as a tablet. If the person cannot swallow, procyclidine 5mg or benzatropine (also known as cogentin) 1mg can be given as an intra-muscular injection. 3. Continue to give procyclidine or benzhexol tablets three times each day. 4. After 2 days try re-starting the anti-psychotic medicine. Try using a lower dose of medicine or change to a different anti-psychotic. Olanzapine is a good choice of anti-psychotic medicine for people who have had acute dystonic reactions.
15.2 Anti-psychotic induced Parkinsonism (AIP) This is a side-effect of anti-psychotics.
Who gets it? About one in every five people who take anti-psychotic medicines get AIP. It usually starts about four weeks after the person has started the medicine. AIP is a reason why many people stop taking their medicine.
What is it like? The person’s arms and legs will shake. They will also be stiff and complain of stiff movements. 131
What do you have to do? 1. Lower the dose of anti-psychotic medicine. 2. Change to a different type of anti-psychotic medicine. Olanzapine is the best anti-psychotic medicine for people who have AIP. 3. Give an anti-cholinergic medicine such as procyclidine or benzhexol (doses are gi ven earlier in this chapter). It is important that you review the need for these medicines regularly as they can make tardive dyskinesia (TD) more likely to happen (see section 15.4 ). Often AIP stops after a few weeks of being on anti-cholinergic medicine so there is no need for people to be on extra medicines for a long time.
15.3 Akathisia This is a side-effect of anti-psychotic and anti-depressant medicines.
Who gets it? About 4 in every 10 people who take anti-psychotic medicines will get akathisia.
What is it like? The person will feel restless or will be unable to sit still.
What do you have to do? 1. Try reducing the dose of medicine. 2. Change the type of medicine. 3. Try adding propranolol . See appendix 1 for instructions on how to use this medicine safely.
15.4 Tardive dyskinesia (TD) This is a long-term side-effect of anti-psychotic medicines.
Who gets it? About one in every 10 people who have been on anti-psychotic medicines for years will get TD.
What is it like? The person will have slow, writhing movements to the tongue, lips, jaw or body. Their eyes may also close tightly.
What do you have to do? 1. Reduce the anti-psychotic medicine to the lowest dose possible. 2. Stop anti-cholinergic medicines such as procyclidine, benzatropine or benzhexol. These medicines can make TD worse. 3. Change to a different type of anti-psychotic. Olanzapine is the best anti-psychotic medicine to give people with TD. 4. Try adding Propranolol . See appendix 1 for instructions on how to use this medicine safely.
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15.5 Neuroleptic malignant syndrome (NMS) and serotonoergic syndrome (SS) This is a rare, serious side-effect of anti-psychotic (NMS) or anti-depressant medicine (SS). These conditions can be fatal.
Who gets it? NMS and SS can happen to about one in every 1000 people who take anti-psychotic or antidepressant medicines. It is more likely to happen if the dose of medicine has been increased very quickly.
What is it like? The person will have a fever (temperature greater than 38 degrees Celsius), high pulse (greater than 100 beats each minute) and have either high or low blood pressure. The person will be confused and have the features of delirium (see section 5.1 ). They may shake and have very stiff arms. They may also pass urine uncontrollably.
What do you have to do? 1. All medicines should be stopped. 2. The person should be admitted to hospital at once. 3. The person will need to be reviewed by a senior doctor in hospital. 4. Blood tests should be performed in the hospital which will show a raised creatinine kinase (CK) and white cell count (WCC). 5. The person will need to have intravenous fluid (IV) and be treated with regular doses of benzodiazepine medicine for stiffness. Dantrolene may need to be given to reduce their temperature. 6. Once the person is better, they must never be given the medicine that caused NMS or SS. This needs to be clearly recorded in their records. The person will need to be seen by a senior mental health worker such as a psychiatrist to decide what medicine they need to take for their mental illness in the future.
15.6 Discontinuation syndrome This is an illness that develops when medicine for mental illness has been stopped suddenly.
Who gets it? Any medicine for mental illness can cause this if the person stops taking their tablets suddenly.
What is it like? The person may complain of dizziness, headaches, nausea and vomiting, lack of energy, restlessness, diarrhoea and pains all over their body. They may also see strange things. These features start about two to five days after the medicine has been suddenly stopped.
What do you have to do? 1. Tell people not to stop medicine suddenly. 2. Put a plan together for what the person will do if they run out of medicine. 133
3. If the medicine is started again, the symptoms will go away. Otherwise the symptoms should go away within 7 days. 4. If a person plans to stop their medicine it is best to talk to them about why this is. If the person wants to stop medicine because of side-effects, explain that things can be done for this (see appendix 1). If the person is better or still wants to stop their medicine it is best do this slowly over one month. The medicine should be reduced by a quarter dose each week.
15.7 Lithium toxicity This is a serious side-effect of the medicine lithium that may be given for bipolar mood disorder / manic depression.
What is it like? The person will shake, be restless and vomit. They will also be confused and have the features of delirium (see section 5.1 ).
Who gets it? Lithium toxicity usually occurs after a person does not drink enough fluid. Physical illness like diarrhoea and vomiting make this more likely to happen.
What do you have to do? The person needs to be admitted to hospital and reviewed by a senior doctor as soon as possible. Whilst in hospital they will be given intravenous fluid until the level of lithium in their body and kidney function returns to normal. 134
CHAPTER 16 Managing violence and aggression
What causes violent behaviour? Many different things cause people to become violent and aggressive. The use of alcohol or illicit drugs can cause people to become violent and aggressive, as can withdrawal from these substances. Some organic disorders such as delirium, dementia and epilepsy can also cause violent behaviour. Finally, pain, fear, anxiety and stress can affect people in different ways. Some people channel their feelings through violent or aggressive behaviour.
Look out for warning signs Sometimes it is possible to be able to see that a person may become violent or aggressive. Look out for the following warning signs: • The person may become restless. • They may make sudden movements; clench their fists or pace about. • Their voice may get louder. • Their facial expression may become tense or angry; they may push out their chin, raise their eyebrows, stare intensely and their skin may change colour (go redder or paler). • The person may refuse to communicate. • The person may make verbal threats or gestures. • If a person is about to strike, they may hold their hands above waist height, tense their shoulders and lower the body. The breathing rate will also quicken.
How to calm a person down If you think a person is about to become aggressive. Don’t panic! The following techniques can ensure your safety and calm the potentially violent person down. • Stay a safe distance away from the person so you cannot get hurt. • Avoid allowing yourself to become trapped in a corner. • Appear calm, self controlled and confident. You may feel tense, but try not to show it. Ensure your body language is not aggressive. • Make eye contact but do not stare at the person. • Engage in conversation; show the person that you are listening to them. Ask what the problem is and encourage them to calm down so you can help them. • Every now and then, you should explain to them what you think they have said. You should just state the facts and not include your opinion. Allow the person to correct any misunderstanding. For example: 135
“Sorry, can I just check what you mean here…?” “Can you just explain a little bit more about what you mean by that…?”
• Describe to the person how you think they feel. This helps the person feel understood and can let the conversation carry on. • Think of how you are going to call for help if the person does not calm down.
If the person continues to get angry after trying the above techniques, raise your voice and give simple, one or two word directions. For example: “please sit”. The most important thing at this point is to safely remove yourself and others from the situation and get help.
You should call the police for assistance in order to control the situation and get the person to a safe place. If you suspect the person has a physical or organic illness (see chapter 5 ) the police should take the person to a medical hospital (see your crisis plan ). If you suspect the person has a mental illness, the police should take the person to a psychiatric hospital (see your crisis plan ). If the person does not have a physical or a mental illness they should be taken to the local police station.
If you are in a healthcare setting that has staff that are able to restrain people who are being violent, the following medicine can be used; haloperidol 10–20mg or lorazepam 1–2mg. These medicines should be given as tablets if the person agrees (check under their tongue to make sure they have swallowed the medicine). If the person refuses to swallow tablets the following medicines can be given by intramuscular injection: • Haloperidol 10 –20mg or lorazepam 1 –2mg. These are the best medicines to use.
• If these are not available, chlorpromazine (largactil) 25 –100mg can be given . Note chlorpromazine can be fatal if mistakenly given intravenously (into a vein). Also give benzatropine (cogentin) 1mg by intramuscular injection to prevent the person having side-effects from the chlorpromazine. • As a last resort, diazepam (valium) 10mg can be given intravenously. Do not give more than 5mg of diazepam in one minute. Monitor the persons breathing rate. Call for emergency help if the breathing rate falls below 10 breaths each minute. Diazepam is very slow acting; always wait at least 4 hours between intravenous doses.
136
Only ever use one medicine for emergency sedation. Always wait at least 4 hours between doses of sedative medicine. Give half of these doses if the person is old, has a physical illness or has never had sedating medications before. As soon as it is safe to do so, record the physical observations (pulse, blood pressure, temperature and breathing rate). These should be measured regularly until the person returns to normal.
People with mental illness can die as a result of restraint and emergency medicine for sedation, it is therefore extremely important that the above guidelines are followed.
The relationship between a person and the mental health workers around them is one of the most important factors in helping a person to recover from mental illness. If a person has had to be restrained and given emergency medicine they will most likely feel frightened, confused or angry. It is important that you speak to the person after an emergency situation and explain to them why they had to be restrained and given medicine. Allow the person to talk about how they feel, try and identify what made them upset and plan how you can avoid an emergency situation from happening again. For example, the person could go for a walk or ask for help the next time they start becoming upset, this may prevent an emergency situation from happening again. 137
CHAPTER 17 Managing your own mental health
Most of the time helping people with mental illness is rewarding and fun. However it is also very busy and tiring work. If you become too tired from your work there is a risk that you will suffer from stress, your own health will suffer and you will not be able to help the people you see. From time to time everybody who works with mentally ill people will feel as though there are too many problems to sort out and that they will not be able to make a difference. Always watch out for the following signs of stress in your own life or the people you work with: Formatted: Problems sleeping or concentrating Bullets and Numbering Becoming impatient or irritable Feeling tense or having aches and pains Drinking more alcohol than normal Being unable to relax and have fun.
It is important to look after your own health so that you are strong enough to help the mentally ill people you see at work. The following are things that every mental health worker should do to stay healthy: Formatted: Have a relaxing pastime that does not involve looking after others (for example listening to music or Bullets and Numbering watching films). Take regular breaks at work no matter how busy things are. Sleep well, eat well and exercise regularly.
Most importantly, it is good to talk to others about how you are feeling. Often it is difficult for family and friends to understand the difficulties of working with mental illness. It is therefore good to speak to other colleagues at work about how you are feeling. Senior members of staff should be available regularly to speak to junior colleagues about any problems they may be having. In many places, mental health workers meet up once a week to speak to each other about difficult cases or problems they have been having. These meetings are very useful as health workers can learn from each other and gain support through difficult times. If there is not one of these groups in your area, it is a good idea to set one up.
Remember, the work you do is very valuable. Therefore you are a very valuable person! Look after yourself – you deserve it!
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Fact sheet 1
My crisis plan
What is a crisis plan? Sometimes we have a problem that we don’t know how to deal with – this is called a crisis. For example, people who are depressed sometimes feel like they want to harm themselves or even kill themselves. These feelings can be very frightening and difficult to stop. Another example is when a person who used to be addicted to alcohol or illicit drugs – starts to drink or take drugs again and they don’t know how to stop themselves. It’s possible to put together a plan to help you deal with a crisis. A good plan can often prevent a situation or crisis from getting worse. Think about how you feel when you are having a crisis, think about what you could do to help yourself feel better. Step 1 ______You could try and talk to someone you are close to. Write their contact details here. If this does not make you feel better, or they are not around, go to the next step.
Step 2 ______You could try and talk to your local BasicNeeds volunteer. Write their contact details here. If this does not make you feel better, or they are not around, go to the next step.
Step 3 ______You could try and talk to your local nurse. Write their contact details here. If this does not make you feel better, or they are not around, go to the next step.
Step 4 ______If you still feel bad you should ask somebody to take you to the nearest hospital, tell them it is an emergency and you need to see a doctor.
Keep this plan somewhere safe. If you ever face a crisis, follow your plan. It will help you deal with the situation and should stop the crisis from getting worse. 139
Fact sheet 2
Sleep hygiene
Sleep is very important. When we sleep our body and mind re-charges, like a battery. Everyone has problems sleeping at times, especially when we feel stressed. If your sleep pattern is disturbed, there are a number of things that can be done to help you. We call this sleep hygiene.
Do Go to bed and get up at the same time each day. Get regular exercise each day, preferably early in the day. Keep your bedroom dark – this will help you to relax. Try and sleep in the quietest part of your home. Ask your doctor for fact sheet 3 – this shows you a relaxation exercise that you can do just before you go to bed.
Do not Exercise just before you go to bed. Excite your mind before going to bed, for example – watching an exciting programme or having an important discussion with someone. Drink caffeine or alcohol before you go to bed. Alcohol may make you feel drowsy but it does not improve sleep and you will wake up in the night to go to the toil et! Smoke before you go to bed, tobacco stimulates your mind. Go to bed when you are too hungry or too full of food. Sleep during the day. Command yourself to go to sleep – this will only make you more alert!
If you can not sleep Get up from your bed, go to another part of your home and do something relaxing like watching a (non-excitable) television programme or read. Return to your bed once you feel sleepy. Do this as many times as you need to. 140
Fact sheet 3
Relaxation exercises
Stress is a big problem for many people. Stress can cause many different illnesses including: depression, headaches and body pain. This exercise is the best way of beating stress – much better than any medicines, and it’s free!
Like physical exercise for the body these exercises can be hard at first. However, the more these exercises are practiced, the easier they become and the less stressed you will feel.
1. Find the darkest and quietest place possible. 2. Make sure nobody will distract you for the next 10 minutes. 3. Lie or sit down in a comfortable position. 4. After about 10 seconds, start to concentrate on your breathing. 5. Breathe through your nose nice and slowly. 6. Count slowly to 3 as you breathe in, and then slowly count to 3 as you breathe out . 7. Once your breathing is nice and slow, try to imagine pleasant words every time you breathe out. The words can be anything that makes you feel relaxed. For example you may imagine the words ‘God is with me’. 8. Once you are comfortable breathing slowly and imagining pleasant words, try and imagine pleasant and relaxing pictures in your mind. For example, you may imagine being with a person who makes you feel safe. Or you may imagine a situation or memory where you felt happy (such as being on the beach or at a family gathering). You can even imagine your favourite colour. 9. Continue to do this for 10 minutes.
If you carry out these 9 steps for 10 minutes every day – you will begin to feel less stressed after a few weeks.
Good luck! 141
Fact sheet 4
Epilepsy (ep – ee – lep - see)
What is epilepsy? Epilepsy is a very common and treatable condition. One in every 100 people in Ghana have epilepsy. People with epilepsy have repeated seizures (or convulsions). There are many different types of seizure. Sometimes a seizure will cause a person to fall to the floor, their body may shake or they may move parts of their body in an unusual way. Other seizures are less obvious, a person may seem to have gone ‘absent’ for a short period of time. What causes epilepsy? Our brains use tiny amounts of electricity to work properly. People with epilepsy sometimes experience an abnormal surge in electricity. This surge causes the brain to get confused for a short time. When the brain is confused, it gives confusing messages to the body – which causes the body to behave in an unusual way. This is a seizure. My outlook Epilepsy is a long-term but controllable condition. If you have epilepsy you can lead a normal life, get married, have children and work. The only thing you should not do is drive, swim alone or work with heavy machinery in case you have a seizure and hurt yourself or someone else. How do I manage epilepsy? Take your medicine exactly like your doctor tells you to. Try and keep note of when you have a seizure and what it was like (ask other people what happened). This will help your doctor make sure that you are on the correct dose of medicine. If you feel a seizure coming, lie down on your side and place something soft under your head such as folded towel. Doing these things means you are less likely to hurt yourself when the seizure does come. Some people find that if they sleep regularly, eat regularly, avoid alcohol, avoid extreme physical exercise and avoid situations that can lead to sudden tension or stress – they are less likely to have a seizure. What if I do not take my medicine? If you stop taking your medicine your epilepsy will come back. You should take your medicine for at least two years after you get better . Only stop your medicine if your doctor tells you to. Epilepsy facts Formatted: Epilepsy is not caused by witchcraft or spirits and is not infectious (you cannot get it from touching). Bullets and Numbering People with epilepsy can eat normal food, they can also safely share food with other people. Medicine used to treat epilepsy can sometimes harm unborn children. Tell your doctor if you plan to have children so they can make sure the medicine is safe. 142
Fact sheet 5
Dementia (dem – en – sha)
What is dementia? Dementia is a condition that mostly affects people over 60 years of age. People with dementia may find that they forget things easily, they may lose their way in places that should be familiar, like their local village. They may even forget who their family is. Some people with dementia appear withdrawn or they may be irritable and get angry easily. Dementia can also cause people to say things they shouldn’t say and behave in a way that is unusual and sometimes hurtful or embarrassing.
What causes dementia? Usually the exact cause of dementia is unknown. The most common cause of dementia is a disease called Alzheimer’s disease. This is a brain disease that causes the brain to stop working as well as it should do.
Outlook Unfortunately dementia nearly always gets worse over time and there is no cure at the moment. Some types of dementia can be treated with medicine, whereas others can not. However, there are things that can be done to help someone with dementia.
How do I help someone with dementia? If you care for someone with dementia, you can try and do the following things to make their life and your life easier: A person with dementia needs a simple, daily routine. This way they become used to their daily tasks and Formatted: Bullets and Numbering are less likely to get confused. Find simple tasks that make the most out of their abilities. If they can still pound fu fu, let them. Let them look after themselves as much as they can. If they can wash themselves, let them. Show love and affection whenever possible. Show them the respect they deserve and let them have privacy where possible. If the person with dementia gets angry – try not to argue back. Stay calm. Remember, they do not mean what they say. If they wander away from home, try to keep your doors locked to stop them. It is a good idea to make sure someone with dementia carries a piece of paper with their name, address and the telephone number of a family member on it. If they get lost people will be able to use the information to bring them safely home. If they have problems eating, try to cut food up into small pieces and do not serve it too hot. If their doctor has given them medicine – make sure they take it.
If you care for someone with dementia – don’t forget to look after yourself too! Fact sheet 6 143
Psychosis (sigh – ko – sis)
What is psychosis? People with psychosis sometimes behave in a strange or unusual way. For example, they may appear restless, aggressive or say things that do not make sense. They may have strange thoughts. For example, they may think that someone is trying to hurt them or that someone has control of their body or mind. They may also see or hear things that nobody else can see or hear. Schizophrenia is a severe form of psychosis.
What causes psychosis? Our brains use lots of important chemicals to carry information. Sometimes there is too much or not enough of one of these chemicals. When this happens it can cause psychosis. Sometimes a physical illness, a medicine, alcohol or illicit drugs can alter these chemicals in the brain and cause psychosis.
Outlook Psychosis is treatable. Once the doctor has found the cause of the psychosis, they will prescribe medicine. If the medicine is taken as advised, the symptoms of psychosis should get better. Once the symptoms of psychosis are managed, it is possible to lead a normal life.
How do I manage psychosis? The following advice may help someone who has controlled psychosis to stay well: Learn to relax, ask your doctor for fact sheet 3 for useful relaxation techniques. Formatted: Bullets and Numbering Try some exercises to help you sleep, ask for fact sheet 2 for more information. Talk to friends, talking about your problems is the best way of managing them. Have fun, try to spend time doing things that make you happy. Solve your problems, write down your problems and try and tackle them one by one.
What if I do not take my medication? If medicine is stopped before it should be, the symptoms of psychosis will come back. People with psychosis need to keep taking medicine for at least 2 years after they get better. Never stop taking medicine unless advised by a doctor.
Psychosis facts Psychosis is not caused by witchcraft or spirits Formatted: Bullets and Numbering Psychosis is not infectious (it cannot be passed on by touching people or sharing food). People with psychosis have a mental illness, they are not bad or lazy people. 144
Fact sheet 7
Depression (dep – reh – shon )
What is depression? Depression is a very common condition. People with depression often feel sad for no reason. They often lose interest in their normal daily activities and may spend their time worrying and feeling tense. It is common for people with depression to get regular headaches or pains in other parts of their body.
What causes depression? There are many possible causes of depression. It may be caused by a very stressful event, like a loved one dying. A person may also become depressed over time if they are unhappy with their personal situation. For example, they may feel lonely, or over worked or under valued. The use of alcohol and illicit drugs can also cause depression.
Outlook It is possible to manage depression. Sometimes this might involve taking medicine and other times it might involve a person talking about their troubles.
How do I manage depression? The following advice may help someone with depression get well and stay well: Learn to relax, ask your doctor for fact sheet 3 for useful relaxation techniques. Formatted: Bullets and Numbering Try some exercises to help you sleep, ask for fact sheet 2 for more information. Talk to friends, talking about your problems is the best way of managing them. Have fun, try to spend time doing things that make you happy. Make a list of your problems and try and tackle them one by one. Sometimes people with depression feel like they want to hurt themselves. If you ever feel this way, contact your nearest health worker. There are always things that can be done to help you.
What if I do not take my medication? If medicine is stopped before it should be, the symptoms of depression will come back. A person with depression needs to keep taking medicine for at least 6 months after they get better. Never stop taking medicine unless advised by a doctor.
Depression facts Depression is not caused by witchcraft or spirits and it is not infectious (you cannot get it from touching Formatted: Bullets and Numbering people or sharing food). People with depression have a mental illness, they are not bad or lazy people.
Fact sheet 8 145
Mania (may – nee – ah )
What is mania? People with mania often feel very happy for no obvious reason; they may believe they have special powers or that they are a special person like the king of the world. People with mania often behave in an unusual way. For example, they may speak very quickly, be sexually inappropriate or they may try and do lots of things but achieve very little. Sometimes people with mania feel very down when they are not feeling high – this is called manic depression.
What causes mania and manic depression? Our brains use lots of important chemicals to carry information. Sometimes there is too much or not enough of one of these chemicals. When this happens it can cause mania. A number of things can upset the balance of chemicals in our brain. A stressful event like a family death, the use of alcohol or illicit drugs, some physical illnesses and some medicines can all alter the balance of chemicals in the brain and cause mania.
Outlook Mania is treatable. The doctor will usually prescribe medicine to treat the mania. If the medicine is taken as the doctor advises, then the symptoms of mania should get better.
How do I manage mania and manic depression? The following advice may help someone who has controlled mania to stay well: Formatted: Take your medicine as your doctor tells you to. Bullets and Numbering Learn to relax, ask your doctor for fact sheet 3 for useful relaxation techniques. Try some exercises to help you sleep, ask for fact sheet 2 for more information. Talk to friends, talking about your problems is the best way of managing them. Have fun, try to spend time doing things that make you happy. Make a list of your problems and try and tackle them one by one. What if I do not take my medication? If medicine is stopped before it should be, the symptoms of mania will come back.
Mania and manic depression facts Mania and manic depression are not caused by witchcraft or spirits and are not infectious (you cannot get it Formatted: Bullets and Numbering from touching people or sharing food). People with mania or manic depression have a mental illness. They are not bad or lazy. Medicine used to treat manic depression can sometimes harm unborn children. Tell your doctor if you plan to have children so they can make sure the medicine is safe for the baby.
Fact sheet 9 146
Mental retardation
What is mental retardation? Some people are born with a condition called mental retardation. People with this condition do not develop in the same way as most other people. Children with mental retardation may have difficulty learning new things, like walking and talking. Mental retardation can be mild, moderate or severe.
What causes mental retardation? Mental retardation occurs when the brain does not develop properly. This can happen when there are problems during childbirth, or when a child has a serious illness when they are very young. However, mental retardation is nobody’s fault.
Outlook It is not possible to cure mental retardation with medicine. However most people with mental retardation can slowly learn new things and make progress with support from their family. A person with mental retardation can still enjoy a happy life.
How do I care for someone with mental retardation? If you care for someone with mental retardation, the following advice may be useful: Try and encourage the child to carry out simple tasks. To make the tasks easier to learn, break them down Formatted: Bullets and Numbering into smaller tasks. Find activities that help you to spend time with the child and get household tasks done at the same time. Try and stimulate the child, talk to them and give them praise and rewards when they succeed in any activity. Try not to overprotect the child and let them do as much as they can, this will increase their self-confidence. Always treat a child with mental retardation with love and kindness.
Mental retardation facts Formatted: Mental retardation is not caused by witchcraft or spirits. Bullets and Numbering Mental retardation is not infectious (you cannot get it from touching or sharing food). People with mental retardation have a special condition, they are not stupid or lazy people. Do not buy any ‘tonics’ to cure mental retardation. They are expensive and they do not work. If you care for someone with mental retardation, don’t forget to care for yourself!
Fact sheet 10 147
Delirium (del – e – ri – um)
What is delirium? A person with delirium may quickly become confused, frightened and aggressive. They may see and hear things that others cannot and have problems sleeping. Delirium is very common.
What causes delirium? Delirium is caused by any physical illness. Common causes include: Formatted: Not having enough fluid in the body. Bullets and Numbering Any fever or infection. Abnormal levels of salt or sugar in the body. An injury to the head. Being drunk or high on illicit drugs. People who drink a lot of alcohol and then suddenly stop can also get delirium. Side-effects from medicine. This can be common in older people.
How do I manage delirium? A person with delirium needs to be taken to a hospital that deals with physical illnesses (not a psychiatric hospital) as quickly as possible. Make sure the person has enough to drink whilst they are being taken there. Once in hospital the person may need to be given some medicine to calm them down whilst the physical illness is being treated.
Outlook Provided the physical illness that is causing the delirium is quickly treated, people usually stop being confused and go back to normal within a few days. The confusion should not come back provided the person does not get physically unwell again in the future. A person who has had delirium should always get treatment as soon as possible for any physical illness.
Delirium facts Delirium is not caused by witchcraft or spirits. Formatted: Bullets and Numbering Delirium is not infectious; you can not get it by touching someone with delirium. People with delirium can safely share food with other people. 148
Appendix 1 The safe administration of medicines for mental illness
The following is a guide to the safe administration of medicines for mental illness. These medicines are very powerful and it is therefore vital that they are used correctly. Failure to do so could have serious consequences for the person taking the medicine.
The following information also explains the side-effects of each medicine and how they should be managed. People often stop taking medicine because of the side-effects. However, common side-effects usually go away in time as the body gets used to taking the medicine. Sometimes reducing the dose of medicine can help to reduce the side-effects. Most rare side effects are serious; in this case the medicine has to be stopped.
Amitriptyline (also known as triptafen or tryptizol) Depression: Start by giving 25mg at night (half this dose in the elderly). Increase the dose gradually every 3 nights until the person is taking 75mg; then wait at least 2 weeks between dose increases. Most adults need between 150–200mg of amitriptyline to get better. Amitriptyline can be given as a divided dose (in the morning and evening) or as a single night time dose. The maximum dose of amitriptyline is 200mg daily. Prevention of migraine: If a person gets more than two attacks each month give 25–75mg at night.
Amitriptyline side- What to do effects Common side-effects Advise the person to chew gum. If this remains a problem, a reduction in dose Dry mouth. Not may be needed. If this is still a big problem after some time, and outweighs the having enough saliva benefit of the medicine, a different medicine may be needed. or spit
Tell the person not to worry, they will not need glasses. If this remains A problem a reduction in dose may be needed. If this is still a big problem after Blurred vision some time and outweighs the benefit of the medicine, a different medicine may be needed. Not being able to pass faeces Advise the person to eat more fruit and vegetables and drink more water. A mild (constipation) laxative from a pharmacy may help.
Not being able to Advise the person to see a health worker urgently. It is likely the medicine will pass urine have to be changed. 149
Advise the person not to drive or operate machinery. They should try taking their medicine at a different time (for example at night so it helps them sleep. If they are sleepy in the morning they should take the medicine earlier the night Feeling too sleepy before).
Advise the person to avoid foods like chocolate, crisps and fizzy drinks. A diet Putting on too much weight of fruit and vegetables will help as will physical activity like walking. Uncommon side-effects
Headache Advise the person to take paracetamol. They should not use pain killers for more than 10 days every month.
Feeling sick Advise the person to take the medicine with or after food.
Reassure the person that this is not dangerous. If this remains a problem, a reduction in dose may be needed. If this is still a big problem after some time A fast heart beat and outweighs the benefit of the medicine, a different medicine may be needed.
Feeling faint on standing up Advise the person not to stand up too quickly. Reassure them that this (hypotension) dizziness is not dangerous.
Lack of interest in sex, Reassure the person that this is not dangerous. If this remains a problem, a problems enjoying sex or reduction in dose may be needed. If this is still a big problem after some time difficulties having erections and outweighs the benefit of the medicine, a different medicine may be (men) needed.
Sweating If this is a bad problem advise the person to see a doctor. Rare side-effects Feeling shaky Advise the person to see a doctor.
Benzhexol (also known as artane, broflex or trihexyphenidyl hydrochloride)
Side-effects from anti-psychotic medicine (see 15.1 and 15.2 ): 1mg daily, increased gradually to a usual dose of 5–15mg daily in 3–4 divided doses. The maximum dose of benzhexol is 20mg daily. In the elderly use the lower doses. Benzhexol should not be used in children.
Benzhexol side-effects What to do Dry mouth. Not having enough saliva or spit See amitriptyline
Blurred vision See amitriptyline
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Not being able to pass faeces (constipation) See amitriptyline
Not being able to pass Advise the person to see a health worker urgently. It is likely the medicine will urine have to be changed. If this remains a problem a reduction in dose may be needed. If Inability to sleep this is still a big problem after some time and outweighs the benefit of the medicine, a different medicine may be needed
Agitation Reduce the dose of medicine. Stop the medicine now. Assess the person for delirium (see section 5.1 ). Confusion
Seeing things that others Stop the medicine now. Assess the person for delirium (see section 5.1 ). cannot (hallucinations)
Memory problems Reduce the dose of medicine. Advise the person not to drive. They should lie down when they feel dizzy and Dizziness not stand up too quickly.
The person should stop the medicine now and see a doctor urgently. Rash anywhere on the They will probably need to be started on a different skin medicine
Benzatropine (also known as benztropine mesylate or cogentin) Side-effects from anti-psychotic medicine (see 15.1 and 15.2): 1–2mg by intramuscular or intravenous injection, repeated if symptoms reappear. In the elderly use lower doses.
Benzatropine side-effects This medicine has the same side-effects as those listed for benzhexol earlier in this appendix.
Carbamazepine (also known as tegretol) Epilepsy: This is the second best choice of medicine to use in generalised epilepsy after sodium valproate. It is the best medicine to use for partial epilepsy. In adults start with 100– 200mg twice daily. Increase the dose slowly, by no more than 100–200mg every 2 weeks. The usual dose needed in adults is 400mg–1200mg given in divided doses daily. The maximum dose of carbamazepine for adults is 2000mg daily.
In children with epilepsy, the medicine should be divided between morning and night time doses; up to 1 year old give 100–200mg daily, 1–5 years old 200–400mg daily, 5–10 years old 400–600mg daily, 10–15 years old 400mg–1000mg daily. Always follow the advice for prescribing in children given at the start of chapter 12.
Mania or manic depression: Carbamazepine should not be used if there are alternatives such as olanzapine or sodium valproate available to treat bipolar mood disorder. If there are no other alternatives, start by giving 200mg twice daily. Increase the dose gradually and give the medicine as a divided dose in the morning and the evening. Most people with mania or bipolar mood disorder need 400–600mg of carbamazepine each day to stay well. The maximum dose of carbamazepine for mania or bipolar mood disorder is 1600mg daily. 151
Carbamazepine side-effects What to do Common side-effects Advise the person not to drive or use machinery. Reassure them they will not Seeing double (diplopia) need glasses. Feeling dizzy, light headed or Advise the person not to drive. They should lie down when they feel dizzy and faint (hypotension) not stand up too quickly. Advise the person not to drive or use machinery. The person can try taking their Feeling sleepy or drowsy medicine at a different time of the day to see if this makes them less drowsy.
Less common side-effects
Nausea and vomiting Taking each dose after food may help.
Uncommon side-effects Being unsteady or having Lower the dose of medicine. difficulties balancing (ataxia). Advise the person to take paracetamol or aspirin. Make sure they do not take Headache painkillers for more than 10 days each month.
Rare side-effects The person should stop taking the carbamazepine now and see a doctor Confusion, red rash, fever, sore urgently. They will probably need to be started on a different medicine. If the throat, mouth ulcers, bruising or person is confused, it is likely that they have developed delirium (see section bleeding 5.1 ). Advise the person to eat more fibre such as fruit, bran or vegetables. They
Constipation should make sure they drink plenty of water. A mild laxative from a pharmacy may help. Reassure the person that this problem will probably go away quite quickly. Diarrhoea or loose stools
Advise the person to monitor this rash. They should stop A mild rash anywhere on the taking carbamazepine and see a health worker if the rash gets worse or they skin develop confusion, red rash, fever, sore throat, mouth ulcers, bruising or bleeding.
Not passing much urine (syndrome of inappropriate ADH Stop the medicine and get the person to see a doctor if possible. secretion)
152
Chlorpromazine (also known as largactil) Psychosis and schizophrenia: start at a dose of 25mg three times daily, or 75mg at night. The dose should be slowly increased, most people with psychosis need between 75–300mg of chlorpromazine to stay well. The maximum dose of chlorpromazine is 1000mg daily.
Chlorpromazine side-effects What to do Common side-effects Feeling restless, the person See section 15.3 may not feel comfortable unless they are moving (akathisia)
Dry mouth, not having much See amitriptyline saliva or spit (an anti-cholinergic side-effect)
Blurred vision (an anti- See amitriptyline cholinergic side-effect) Constipation (an anti-cholinergic See amitriptyline side-effect) Difficulty passing urine (an Advise the person to see a qualified health worker as soon as possible. They anti-cholinergic side-effect) may need to be given a different medicine.
Drowsiness See carbamazepine Strange movements such as See section 15.1 shaking, tremor. Abnormal movements to the neck, eyes or tongue (acute dystonic reactions)
Menstrual problems or breast Reassure the person that this often goes away in a few weeks. If it does not, try a tenderness in women, lower dose or a different medicine. Olanzapine has the fewest sexual side-effects impotence in men. Milk of the anti-psychotics available in Ghana. secretion from the breasts or problems enjoying sex in both men and women (raised prolactin)
Weight gain Advise the person to avoid fatty foods like chocolate, crisps and fizzy drinks. A diet full of vegetables and fibre will usually help as will physical activities such as walking. Uncommon side-effects 153
Feeling, dizzy light headed or See carbamazepine faint (hypotension) Reassure the person this is not usually dangerous. Advise them to see a Having a fast heart beat health worker for a physical check up if it remains a problem. (palpitations)
Swollen ankles (peripheral Reassure the person this is nothing to worry about. Get a qualified health oedema) worker to do a cardiovascular examination on the person. If it remains a problem, change to a different medicine.
Rare side-effects Skin going blotchy or getting Advise the person to avoid their skin being exposed to strong sunlight. They easily burned in the sun should wear long clothes and a hat or use sun screen. (photosensitivity) Skin rashes Advise the person to stop taking the medicine and see a health worker now. It is likely they will need to be started on a different medicine.
The liver not working normally, Advise the person to stop taking their medicine. Repeat the blood tests to this is usually only discovered make sure the liver is returning to normal. If it does not, ask a doctor for if blood tests are taken. advice. Change the anti-psychotic medicine (haloperidol is the best anti- However the person may be psychotic medicine for people with liver problems). sleepy, lose their appetite and the skin / eyes may look yellow
Very rare side-effects Fever, stiffness, drowsiness Stop the medicine now and seek help. See section 15.5 (neuroleptic malignant syndrome) Arrange for the person to have a Full Blood Count (FBC). If the medicine has Sore throat, fever, generally made the persons white cell count decrease, consult a doctor for advice. The feeling unwell person will need to be started on a different medicine. (agranulocytosis)
Diazepam (also known as valium) Anxiety: start with 2.5mg three times daily, increased if necessary, to 15–30mg daily in divided doses. The maximum dose of diazepam is 30mg daily. Diazepam should never be used for more than two weeks to treat anxiety because a person can become dependent on this medicine (see chapter 6 for more information on dependency).
Emergency treatment of epilepsy: In adults give 10mg slowly into a large vein (intravenously). 154
Do not give more than 5mg each minute. Monitor breathing rate, if the person’s breath falls below 10 breaths each minute do not give any more diazepam and call for urgent help. Wait at least 10 minutes before giving another 10mg if the seizure is not controlled. After giving 20mg of diazepam wait at least 60 minutes before giving any more diazepam. The maximum dose of diazepam is 30mg in 24 hours. In a child give 1mg of diazepam for each year of the child’s age. For example, a 4 year old child should be given 4mg of diazepam. Remember to give the medicine slowly and monitor the child’s breathing rate. See chapter 12 for normal physical observations in children.
Diazepam side-effects What to do Common side-effects Seeing double (diplopia) See carbamazepine See carbamazepine Feeling dizzy, light headed or faint
Feeling sleepy or drowsy See carbamazepine Rare side-effects Feeling excitable, over talkative, unfriendly or Gradually reduce and stop the medicine. aggressive Reassure the person this is not serious. Reduce the dose of Memory problems (amnesia) medicine if this remains a problem.
Check to make sure the person does not have delirium (see Confusion section 5.1 ). Stop the medicine and get the advice of a senior health worker. Headache See carbamazepine Feeling dizzy, light headed or faint See carbamazepine (hypotension) Stop the medicine now. Get the advice of a senior health Blotches or rash anywhere on skin worker.
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Fluoxetine (also known as prozac) In depression that has not responded to talking therapy: 20mg once daily increased after 3 weeks if necessary. The usual dose of fluoxetine is 20–60mg daily, in the elderly the usual dose is 20–40mg daily. The maximum dose of fluoxetine is 80mg daily in adults, in the elderly the maximum dose is 60mg. Fluoxetine should not be used in those under 18 years old.
Obsessive compulsive disorder: initially give 20mg once daily increased as for depression. The usual dose of fluoxetine and the maximum doses are the same as for depression.
Post traumatic stress disorder: give as for depression.
Fluoxetine side-effects What to do Common side-effects Feeling anxious or restless Reassure the person that this will usually wear off. If it remains a problem try lowering the dose or using a different medicine. Make sure you explain to the person that they should contact a health worker if they feel like harming themselves or anyone else.
Diarrhoea Reassure the person that this will usually go away. If it remains a problem, try lowering the dose or using a different medicine. Problems sleeping Tell the person to take their medicine in the morning.
Loss of appetite Reassure the person that this will go away. If it remains a problem, try lowering the dose or using a different medicine.
Nausea and vomiting Taking each dose after food may help Fairly common side-effects Lack of sexual interest or enjoyment Reassure the person that it is the medicine causing this and Problems having erections (men) there is nothing wrong with them. It may wear off in time. If it remains a problem try a lower dose or a different medicine.
Uncommon side-effects Feeling dizzy, light headed or faint See carbamazepine (hypotension)
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Drowsiness Advise the person not to drive or use machinery. Try taking the medicine at a different time of the day.
Headache See carbamazepine Rare side-effects Dry mouth, not having much saliva or spit (an See amitriptyline anti-cholinergic side-effect) Rash on the skin or itching Stop the medicine now. Get the person to be reviewed by a senior health worker such as a doctor.
Shaking If this remains a problem reduce the dose or change the medicine. Not passing much urine (syndrome of Stop the medicine and get the person to see a doctor if inappropriate ADH secretion) possible. Very rare side-effects Fever, stiffness, drowsiness (serotonin Stop the medicine now and seek help. See section 15.5 . syndrome)
Fluphenazine hydrochloride injections (also known as modecate) Psychosis and schizophrenia: These injections are very slow acting. It may take more than 1month for the medicine to start reaching the different parts of the body. It may also take more than 1 month for any side-effects to wear off once an injection has been given. For this reason a test dose of injection should always be given. In adults this is 12.5mg of fluphenazine hydrochloride, whilst in the elderly this test dose should be 6.25mg. Wait 1 week to see if the person has any extreme side-effects before giving another injection. If the person has extreme side-effects, do not give another injection, instead speak to a senior colleague for advice (see your crisis plan ). Most people with psychosis need between 12.5–100mg of fluphenazine hydrochloride to stay well. The injections should be given every 2 to 4 weeks. Always wait at least 2 weeks between injections. Remember to be extremely patient when waiting for an injection to work. Always wait at least 6 weeks before increasing the dose of injected medicine.
Injections can be very painful so do not give more than 2–3mls of injection at any one site. Always record which side of the body an injection is given on. Injections should be given using the Z track technique which means the injection is less painful. 157
The Z track technique 1. Wash your hands and put on disposable gloves. 2. Ask the patient to sit or lie in a relaxed position. 3. Select an injection site in the upper and outer quadrant of the gluteus maximus muscle. Do not use a site with any evidence of tenderness, irritation or abscesses. 4. Wipe the injection site with a sterile swab and wait for it to dry. 5. Draw back the skin at the injection site before inserting the needle deep into the muscle at a 90 degree angle. 6. Draw on the needle to make sure a blood vessel has not been punctured. If blood appears withdraw the needle, discard the medicine and select another injection site. 7. Inject the medicine slowly at a rate of 1ml every 10 seconds. If resistance is felt, stop the procedure and ask a senior colleague for assistance. 8. Once all the medicine has been given wait for 10 seconds before quickly withdrawing the needle. Release the skin. Apply gentle pressure with cotton wool. Do not massage the injection site. 9. Dispose of the needle safely.
Formatted: Alternating the side of the body on which the injection is given can prevent painful lumps from developing. Bullets and Numbering A person may need to be on anti-psychotic tablets whilst an injection is being started. However, once a person has had several injections the tablets should be slowly stopped. Never routinely give anti-psychotic injections and anti-psychotic tablets; this can lead to dangerous side- effects. Never use fluphenazine as a sedative; it does not work in this way. Never use fluphenazine as a ‘booster’ to tablets, it does not work in this way. Always consider a person’s circumstances when deciding whether to start them on injection or tablets. A person will have to be able to see a health worker regularly in order to keep receiving injections.
Fluphenazine hydrochloride side-effects This medicine has the same side-effects as those listed for chlorpromazine earlier in this appendix.
Haloperidol (also known as haldol, dozic or seranace) Psychosis and schizophrenia: start at a dose of 2.5–5mg given two to three times daily and increased slowly. Most people with psychosis need between 5–10mg of haloperidol daily to stay well. The maximum dose of haloperidol is 30mg each day. 158
Agitation in delirium and dementia; give 2.5–10mg by mouth or by intramuscular injection if the person cannot swallow tablets. Because the person’s body will be weak you need to wait at least 4 hours before you give any more medicine. Give no more than 30mg of haloperidol every 24 hours (including the regular doses the person may be prescribed for psychosis). Do not keep giving the haloperidol once the person has calmed down.
Haloperidol side-effects This medicine has the same side-effects as those listed for chlorpromazine earlier in this appendix.
Imipramine Depression: start by giving 37.5mg at morning and at night. Increase the dose gradually; wait at least 2 weeks between dose increases. Most adults need between 150–200mg of imipramine daily to get better. Imipramine should always be given as a divided dose. The maximum dose of imipramine is 200mg daily. In the elderly start with 10mg of imipramine daily. Increase the dose gradually. Most elderly people need between 30–50mg of imipramine to get better. The maximum dose of imipramine in the elderly is 50mg daily.
Imipramine side-effects This medicine has the same side-effects as those listed for amitriptyline earlier in this appendix.
Lorazepam Anxiety: give 1–2mg daily, divided into morning and night time doses. Use half these doses in the elderly or physically ill. The maximum dose of lorazepam is 4mg daily . Lorazepam should never be used for more than two weeks to treat anxiety because a person can become dependent on this medicine (see chapter 6 for more information on dependency).
Lorazepam side-effects This medicine has the same side-effects as those listed for diazepam earlier in this appendix.
Olanzapine (also known as zyprexa) Psychosis and schizophrenia: If available this is the first medicine you should try giving a person with psychosis. Start with 10mg at night. People with psychosis usually need between 5–20mg each day to stay well. The maximum dose of olanzapine is 20mg daily. Only give doses over 10mg after reassessing a person. 159
A side-effect of olanzapine is weight gain, which can lead to diabetes. Ideally people who take olanzapine should be checked for diabetes every 6 months by checking blood glucose levels or by dipstick analysis of urine. If a person develops diabetes they should see a health worker who is qualified to deal with this problem. In many cases the diabetes can be controlled through eating a healthy diet. If diabetes continues to be a problem, other medicines for psychosis such as chlorpromazine or haloperidol should be used. Mania and manic depression: If available, this is the first choice medicine to treat mania and manic depression. In adults start at a dose of 15mg. Usually people with mania or manic depression need between 5–20mg of olanzapine each day to stay well. The maximum dose of olanzapine for mania and manic depression is 20mg daily.
Olanzapine side-effects This medicine has the same side-effects as those listed for chlorpromazine earlier in this appendix.
Phenobarbitone (also known as phenobarbital) Epilepsy: This can be used for generalised seizures. In adults start with 60mg given at night. Increase the dose slowly; the maximum dose of phenobarbitone is 180mg, given at night. In children give 5–8mg for each 1 kilogram of the child’s weight each day. Always follow the advice for prescribing in children given at the start of chapter 12.
Phenobarbitone can cause anaemia as a side-effect. It is therefore a good idea to give people 5mg of folic acid daily to prevent this side-effect.
Phenobarbitone side-effects What to do Memory problems (amnesia) Reassure the person this is not serious. Reduce the dose of medicine if this remains a problem. Feeling dizzy, light headed or faint See carbamazepine (hypotension) Being unusually excited, seeing things that The person is likely to have developed are not there (visual hallucinations), delirium (see section 5.1 ). Stop the confusion, drowsiness medicine now and give urgent treatment for delirium. Irregular or jerky movements This can be a side-effect from the phenobarbitone or a symptom of epilepsy. Consult a senior health worker for advice.
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Bruising, nose bleeds, sore throats or The person needs to have urgent blood tests infections such as full blood count, clotting, liver and renal function. If these tests are abnormal or are not available, the medicine will need to be changed. If the phenobarbitone is only causing megaloblastic anaemia, this can be treated with folic acid. Always consult a senior health worker if there are blood abnormalities.
Yellow colour appearing in the eyes or skin Stop the medicine now. Advise the person to (jaundice), abnormal liver function blood tests see a senior health worker for a check up and blood tests. Rash or blistering of the skin (allergic skin Stop the medicine now. Advise the person to reactions) see a senior health worker for a check up.
Phenytoin (also known as epanutin) Epilepsy: This can be used for generalised seizures. In adults start with 75mg given twice daily. Increase the dose slowly; wait at least 2 weeks before increasing the dose of phenytoin. Usually increase the dose in steps of 30mg. The usual dose needed in adults is 200–500mg daily. The maximum dose of phenytoin in adults is 500mg daily. Phenytoin is not recommended for use in children as it can cause permanent learning disabilities. Phenytoin can cause anaemia as a side-effect. It is therefore a good idea to give people 5mg of folic acid daily to prevent this.
Phenytoin side-effects What to do Constipation See carbamazepine Unusual eye movements, shaking, loss of Lower the dose of phenytoin. Make sure the feeling, dizziness, difficulties sleeping, slurred person is also taking folic acid 5mg once speech, headaches daily with their phenytoin. Spots (acne) Encourage the person to wash their face regularly. Growing excessive hair (hirsutism) Reassure the person. If it remains a problem lower the dose or change the medicine
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Being unusually excited, seeing things that The person is likely to have developed are not there (visual hallucinations), delirium (see section 5.1 ) and needs urgent confusion, drowsiness treatment for this. Stop the medicine now.
Bruising, nose bleeds, sore throats or The person needs to urgently have blood infections tests such as full blood count, clotting, liver and renal function. If these tests are abnormal or are not available, the medicine will need to be changed. If the phenytoin is only causing megaloblastic anaemia, this can be treated with folic acid. Always consult a senior health worker if there are blood abnormalities. Yellow colour appearing in the eyes or skin Stop the medicine now. Advise the person to (jaundice), abnormal liver function blood tests see a senior health worker for a check up and blood tests. Rash or blistering of the skin (allergic skin Stop the medicine now. Advise the person to reactions) see a senior health worker.
Procyclidine (also known as kemadrin or arpicolin) Side-effects from anti-psychotic medicine (see 15.1 and 15.2 ): 2.5mg tablets can be given 3 times daily, increased gradually to a maximum dose of 30mg daily. Procyclidine can also be given by intramuscular or intravenous injection. 5 –10mg can be given, it is usually effective in 5–10 minutes but it may need up to 30 minutes to work. Always use lower doses in the elderly when giving procyclidine.
Propanolol (also known as inderal) Anxiety: Start with 40mg given two to three times daily. Most people with generalised anxiety disorder need to be given between 80–160mg of propanolol daily in order to feel better. The maximum dose of propanolol is 160mg daily.
Prevention of migraine: If a person gets more than two attacks each month, give propanolol as described above for anxiety. 162
Never give propanolol if a person has asthma (episodes of wheezing or difficulties in breathing), heart problems, low blood pressure or a pulse rate of 60 beats per minute or lower. Always check blood pressure and pulse before giving propanolol.
Propanolol side-effects What to do Common side-effects Feeling cold in the fingers or toes Explain to the person that this normally goes away after about 1 week. If it does not, lower the dose of medicine. Feeling tired all the time Explain to the person that this normally goes away after about 1 week. If it does not, lower the dose of medicine. Uncommon side-effects A very slow pulse (under 50 beats per minute) Stop the medicine. Ask a senior health worker such as a doctor to review the person. Feeling dizzy, (hypotension) light headed or faint See carbamazepine Lack of interest in sex Problems having erections Reassure the person. Consider lowering (men) the dose or changing medicine if this remains a problem Problems sleeping or nightmares Explain to the person that this normally goes away after about 1 week. If it does not, lower the dose of medicine. Nausea or diarrhoea Explain to the person that this normally goes away after about 1 week. If it does not, lower the dose of medicine. Difficulties breathing or chest tightness (asthma) Stop the medicine now. Get the person to be reviewed by a senior health worker such as a doctor.
Rare side-effects Dry eyes Get the person to be reviewed by a senior health worker such as a doctor. Rash on the skin Stop the medicine now. Get the person to be reviewed by a senior health worker such as a doctor.
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Sertraline (also known as lustral) Depression: Start by giving 50mg in the morning. Increase the dose gradually in steps of 50mg. Always wait at least 2 weeks between dose increases. Most people only need to be on 50mg of sertraline to stay well once they have got better. The maximum dose of sertraline is 200mg daily. Sertraline should not be given to those under 18 years of age.
Obsessive compulsive disorder: give as for depression.
Post traumatic disorder: initially give 25mg daily, increase dose after 1 week to 50mg daily. If necessary the medicine can then be increased in steps of 50mg over several weeks to a maximum dose of 200mg daily.
Sertraline side-effects This medicine has the same side-effects as those listed for fluoxetine earlier in this appendix.
Sodium valproate (also known as epilim or convulex) Epilepsy: If available this is the best choice of medicine to use for generalised epilepsy. Start with 300mg twice daily. Gradually increase the dose by 200mg every three days until the person starts to get better. The following doses can be used for children with epilepsy; the medicine should be divided between morning and night-time doses; in children who weigh below 20kg start by giving 20mg per kilogram of the child’s weight. In children who weigh more than 20kg, start by giving 200mg twice daily. Most children need 20–30mg of sodium valproate for each kilogram of their weight. The maximum dose in children is 35mg per kilogram of the child’s weight. Always follow the advice for prescribing in children given at the start of chapter 12 .
Mania or manic depression: If olanzapine is not available, sodium valproate is the next best medicine to treat bipolar mood disorder. Give in the same way as for epilepsy. Most people with mania or manic depression need between 1000–2000mg of sodium valproate to get better.
The maximum dose of sodium valproate is 2500mg daily. This medicine should not be given to woman who may become pregnant due to the harmful effects it may have on an unborn baby. See chapter 10 for the best medicine to use for women who intend to get pregnant.
Sodium valproate side-effects What to do Common side-effects Taking each dose after food may help. Give slow release Nausea and vomiting tablets if possible. Uncommon side-effects 164
W eight gain Advise the person to avoid fatty foods like chocolate, crisps and fizzy drinks. A diet full of vegetables and fibre will usually help as will physical activities such as walking.
Rare side-effects
Being unsteady or having Lower the dose of medicine. difficulties balancing (ataxia). Confusion Check to make sure the person does not have delirium (see section 5.1 ). Stop the medicine and get the advice of a senior health worker. Drowsiness See carbamazepine
Hair loss Discuss this with a senior health worker. If it is a serious problem, the medicine may have to be changed. The liver not working normally, Advise the person to stop taking their medicine. Repeat the this is usually only discovered if blood tests to make sure the liver is returning to normal. If it blood tests are taken. However does not change, ask a doctor for advice. Change the the person may be sleepy, lose epilepsy medicine ( carbamazepine is the best epilepsy their appetite and the skin/ eyes medicine for people with liver problems). may look yellow. Tremor Lower the dose of medicine. Very rare side-effects Stop taking the sodium valproate now and consult a senior A rash anywhere on the skin health worker. Stop taking the sodium valproate now and consult a senior Bruising, nose bleeds. health worker.
Trifluoperazine (also known as stelazine) Psychosis and schizophrenia: start by giving 5mg twice daily. Increase by 5mg after one week, then at intervals of 3 days according to response. In the elderly reduce these doses by at least half.
Trifluoperazine This medicine has the same side-effects as those listed for chlorpromazine earlier in this appendix. 165
Appendix 2 Emergency treatment of physical illness
As discussed earlier in this manual, mental illness commonly presents with physical illness. If you discover a person has a physical illness, this needs to be treated immediately (before treating any mental illness). If left untreated, physical illnesses can kill. A person with physical illness should be taken to a medical hospital (rather than a psychiatric hospital) or to a qualified health professional. The following five steps can help health workers save the lives of those with physical illness, whilst the person is being transferred to hospital.
1) Monitor physical observations Regularly checking pulse, temperature, blood pressure, respiratory rate and capillary refill time is the best way to tell if a person is seriously unwell. If a persons condition changes, always recheck their physical observations. Normal values for physical observations are given in section 2.5 for adults and chapter 12 for children.
2) Give the person enough fluid People with physical illness lose fluid through sweating, vomiting and diarrhoea. They quickly become dehydrated. In a country with a hot climate dehydration can soon kill people with physical illness (particularly children). Therefore one of the most important steps in helping someone with physical illness, is to make sure they have enough fluid in their body. Key features of dehydration include: Thirst Formatted: Bullets and Numbering Decreased passing of urine Urine that is darker than usual Headache Dry mouth / tongue Dizziness on standing. The following signs can also indicate a child is dehydrated: Being drowsy, unconscious or floppy Drinking poorly or being unable to drink A capillary refill time of more than 3 seconds (see section 2.5 ) Dry, sunken eyes Absent tears.
You can also find evidence that a person is dehydrated from the history of the problem (vomiting, diarrhoea, fever) and the physical observations / examination. Raised pulse, low blood pressure and increased capillary refill time show a person is dehydrated. If a person has high blood 166 pressure, consult a senior health worker before giving the person fluids. This is to make sure the person does not have confusion due to high blood pressure which can be made worse by giving fluids (hepatic encephalopathy).
Always suspect dehydration if a person is drowsy or confused.
Use oral re-hydration salts (ORS) if possible, to re-hydrate a person. This will replace essential salts and sugars that they have lost. To prepare ORS first wash your hands and those of the person who is ill. Then dissolve the contents of one sachet of ORS in 600mls (2 small coke bottles) of clean water. If prepared ORS is not available, a home-made solution can be made cheaply. Mix 8 level teaspoons of sugar and 1 level teaspoon of table salt into 1 litre of clean water. Fructose (fruit sugar) or artificial sweeteners should not be used instead of sugar as they may increase diarrhoea and do not provide sufficient energy. Half a mashed banana can be added to each litre of home made ORS both to add potassium and to improve taste. If commercial solutions are used, true rehydration solutions should be used and sports drinks should be avoided (especially in younger children) as these solutions contain too much sugar and not enough essential salts.
The amount of re-hydration that is needed depends on the size of the individual and the degree of dehydration. A rough guide to the amount of ORS solution needed in the first 4–6 hours of treatment for a mildly dehydrated person is: Up to 5 kg (11 lb): 200–400 ml Formatted: Bullets and Numbering 5–10 kg (11–22 lb): 400–600 ml 10–15 kg (22–33 lb): 600–800 ml 15–20 kg (33–44 lb): 800–1000 ml 20–30 kg (44–66 lb): 1000–1500 ml 30–40 kg (66–88 lb): 1500–2000 ml 40+ kg (88 lb): 2000–4000 ml
If weighing scales are not available you can estimate a child’s weight using the following equation:
Weight in kg = (age in years + 4) x 2
Adults and children with dehydration who are not vomiting should be encouraged to drink these solutions in addition to their normal diet. When vomiting occurs, rest the stomach for ten minutes 167 and then encourage the person to slowly start drinking again. Additional ORS should be given each time the person has diarrhoea or vomits. In children less than 2 years old, give an additional 50–100mls of ORS Formatted: Bullets and Numbering In children 2–10 years, give an additional 100–200mls of ORS In those over 10 years, give an additional 100–200mls of ORS
Start with a teaspoonful every five minutes in children and a tablespoonful every five minutes in older children and adults.
Never give anti-diarrhoea medicines such as Mist Kaolin, co-phenotrope, codeine or loperamide to someone who is dehydrated. These medicines are likely to do more harm than good to the person, instead replace the fluid the person is loosing and treat the cause of the problem (see step 3).
If the person is weak it can be useful to slowly give the ORS from a syringe (with no needle!) directly into the person’s mouth. This means small amounts of ORS can be gradually given and you can keep track of how much fluid the person has had. This method is very useful for giving fluids to young children (they can suckle on the syringe). If the person is too weak or drowsy to drink ORS in this way they will need to be given intravenous (IV) fluids. IV fluids should be given in hospital and be monitored by a senior health worker such as a doctor.
Re-hydration is generally adequate when the person no longer feels thirsty and has gone back to passing urine normally. The person’s physical observations will also return to normal confirming they are no longer dehydrated. If the person’s eyes become puffy whilst they are being re- hydrated too much fluid is being given. Once the person is re-hydrated, they may resume eating normal foods when any nausea passes.
3) Reduce any high temperature Give paracetamol. In adults give 1000mg every 4–6 hours. The maximum dose in adults is 4000mg in 24 hours. In children from 3 months to 1 year give 60–120mg, in those 1 to 5 years old give 120–250mg, in those 6–12 years old give 250–-500mg. These doses in children can be repeated every 4–6 hours. The maximum is 4 doses in 24 hours for children. Paracetamol will usually need to be taken regularly for a few days whilst you treat the cause of the high temperature.
4) Treat any infection present Malaria (headache, fever, chills, shaking, abdominal pain, diarrhoea, bitter taste in the Formatted: Bullets and Numbering mouth). Give a 3 day treatment course of artesunate / amodiaquine. In adults give artesunate 168
200mg and amodiaquine 600mg daily. In children less than 1 year old give artesunate 25mg and amodiaquine 75mg daily. In children aged 1–6 give artesunate 50mg and amodiaquine 150mg daily. In children age 7–13 give artesunate 100mg and amodiaquine 300mg daily. If a person with malaria is too unwell to swallow they need to be treated with IV quinine. This should be given in hospital under the supervision of a doctor.
Chest infections (cough, yellow or green sputum, fever, shortness of breath) give amoxicillin Formatted: Bullets and Numbering tablets 250mg every 8 hours for 1 week. Give 500mg every 8 hours for 1 week in severe infections. The same dose of amoxicillin can also be given as an intramuscular (IM) injection or by intravenous infusion (IV) if available. In children up to 10 years old give 125mg every 8 hours for 1 week, double the dose in severe infections. If an adult is allergic to penicillin/ amoxicillin give erythromycin tablets 500mg every 6 hours for 1 week. If the person is so ill they cannot swallow tablets they should be given Benzylpenicillin 1–2 mega units 6 hourly for 2 days. After this they should be able to take tablets and should start a course of amoxicillin tablets as described above.
Urinary tract infections (pain on urination, increased frequency of passing urine, dark or Formatted: Bullets and Numbering offensive smelling urine, fever) give amoxicillin as above. co-trimoxazole can also be used. Doses should be given every 12 hours for 1 week. In adults give 960mg. In children aged 6 months to 5 years give 240mg. In children aged 6–12 years give 480mg. If the person is too sick to swallow tablets, co-trimoxazole can be given as an IV infusion. In adults give 960mg every 12 hours increased to 1440mg in severe infections. In children give 36mg per kilogram of the child’s weight, in severe infections give 54mg per kilogram.
Typhoid (tiredness, headache, fever, cough, diarrhoea). Give ciprofloxacin every 12 hours for Formatted: Bullets and Numbering 2 weeks. In adults give 500mg. In children give 10mg per kilogram of body weight. If the person cannot swallow ciprofloxacin can be given IV. Give adults 200mg every 12 hours, children can be given the same IV dose as for tablets. Revert back to tablets as soon as the person is able to swallow.
Bacterial diarrhoea (diarrhoea, abdominal pain, fever, blood in the faeces). Give Formatted: Bullets and Numbering cotrimoxazole as described above.
Giardiasis and amoebiasis (diarrhoea, abdominal pain, blood in the faeces, no fever). Give Formatted: Bullets and Numbering metronidazole tablets every 8 hours for 5 days. In adults give 800mg. In children up to 3 years old give 100mg. In children aged 4–7 give 200mg. In children aged 8–12 give 400mg.
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Cholera (diarrhoea, abdominal pain, faeces like ‘rice water’). In adults give tetracycline tablets Formatted: Bullets and Numbering 500mg every 6 hours for 3 days. In children give a 3-day course of co-trimoxazole using the doses described above.
Meningitis (drowsiness, neck stiffness, severe headache, difficulties looking at bright lights, Formatted: Bullets and Numbering vomiting). This condition needs to be treated in hospital. In adults give benzylpenicillin 4 mega units IV every 4 hours for at least 1 week then amoxicillin tablets 500mg every 8 hours for the second week. Also give chloramphenicol 100mg IV every 6 hours for 1 week then chloramphenicol tablets 500mg every 6 hours for the second week. In adults cetriaxone can also be used as an alternative to benzylpenicillin. Give 2000mg– 4000mg IV daily for 7 days then give amoxycillin for the second week as described above. In children give benzylpenicillin 0.2 mega units per kilogram of body weight IV every 6 hours plus chloramphenicol 25mg per kilogram of body weight IV every 6 hours. Intravenous antibiotics should be continued for 10 days in children.
5) Reduce the amount of medication the person is on for mental illness. A person with physical illness will be weak whilst they are unwell. These people will be much more likely to have dangerous reactions to the medicines used to treat mental illness. Most medicines for mental illness also cause drowsiness (which is a sign of delirium). If a person with physical illness is given medicine that makes them drowsy you will not be able to tell if they are getting better from the physical illness. It is therefore a good idea to reduce or stop the dose of any medicine for mental illness a person is taking whilst they are physically unwell. Once the person is better they can gradually go back to the dose they were on before they became physically unwell (if needed). The only exception to this is epilepsy. When a person is unwell they are more likely to have seizures. However the medicine used to treat epilepsy can also make drowsiness and confusion worse. If you have a person with epilepsy who has a physical illness, it is best to consult a senior health worker about whether to change the dose of their epilepsy medicine 170
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8. National Institute of Clinical Excellence (NICE). Depression in children and young people. Clinical Guideline 28. September 2005. National Health Service (UK).
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11. National Institute of Clinical Excellence (NICE). Obsessive Compulsive Disorder. Core interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder. Clinical Guideline 31. November 2005. National Health Service (UK).
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Last accessed 25/07/07.
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Essential Skills for Mental Health Care is a vital resource for anyone working in mental health. It provides an overview of what mental illness is and what causes mental illness. It explains how to assess and diagnose mental illness, how to manage mental illness and the available treatment options. This manual can be used as both a training resource and a reference tool for use in the field. There are also a number of fact sheets that can be photocopied for people with mental illness or their carers.
“This manual is a very good companion to the student of mental health.” Dr Akwasi O. Osei, Acting Chief Psychiatrist, Ghana Health Service.
“This manual will serve as a good working tool for mental health professionals at all levels.” Mr Winfred Darko, Community Psychiatric Nurse, Accra, Ghana.
“This manual will be very useful to volunteers in the field. It will allow us to teach ourselves about mental illness.” Kingsley Nettey and Lydia Ashiley, BasicNeeds Volunteers, Ghana.
Essential Skills for Mental Health Care can be downloaded from the BasicNeeds website: www.basicneeds.org.uk
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